Perioperative solutions for rapid recovery joint arthroplasty: get ahead and stay ahead

Perioperative Hematological Outcomes of Simultaneous Double Total Joint Arthroplasty for Hemophilic Arthritis of the Hip and Knee: A Retrospective Study

BACKGROUND

Double total joint arthroplasty (TJA) can reduce repeat hospitalizations and total coagulation factors usage in hemophilic arthritis (HA) patients who have multiple joint involvement, but the risk of perioperative adverse events with double TJA must be considered.

METHODS

We reviewed 50 patients who had hemophilia A, including 26 single TJA (STJA) (13 total knee arthroplasty [TKA] and 13 total hip arthroplasty [THA]) and 24 simultaneous double TJA (Sim-DTJA) (including 10 bilateral TKAs, 10 bilateral THAs, and four patients who had simultaneous THA and TKA). Length of hospitalization, blood loss, total exogenous coagulation factor VIII (FVIII) usage, perioperative FVIII levels, perioperative activated partial thromboplastin time, perioperative transfusion rates, and postoperative complications were assessed and compared.

RESULTS

Perioperative FVIII levels and activated partial thromboplastin time were not different between Sim-DTJA and STJA. Total blood loss (1,216.0 ± 450.4 mL) and hidden blood loss (1,020.0 ± 419.9 mL) were slightly higher in Sim-DTJA than in STJA (1,062.0 ± 371.8 mL and 929.9 ± 351.6 mL, respectively) (P = 0.192, P = 0.416, respectively). The length of hospitalization between the Sim-DTJA (10.6 ± 1.8 days) and the STJA (10.4 ± 1.7 days) was not different (P = 0.802). The perioperative FVIII usage was 30,063 ± 6,466 international unit for Sim-DTJA and 26,077 ± 12,524 international unit for STJA (P = 0.008). No postoperative adverse events and prosthesis-related complications were reported in any of the patients. The two cohorts had no perioperative transfusion of erythrocyte and platelets.

CONCLUSION

In HA patients who had multiple joint involvements, Sim-DTJA can achieve clinical efficacy without significantly increasing perioperative blood loss, length of hospitalization, and postoperative complications.

Personalized Stem Length Optimization in Hip Replacement: A Microscopic Perspective on Bone-Implant Interaction

Total hip replacement (THR) surgery involves the removal of necrotic tissue and the replacement of the natural joint with an artificial hip joint. The demand for THR is increasing due to population aging and prolonged life expectancies. However, the uniform length and shape of artificial hip joints can cause stress shielding, leading to implant loosening and femoral fractures. These issues arise because these designs fail to account for the unique anatomical and biomechanical characteristics of individual patients. Therefore, this study proposes and validates a method to optimize stem length by considering bone microstructure and daily load. The results demonstrated that the optimal stem length varies with loading conditions and significantly reduces stress in the cortical bone while maintaining an appropriate strain energy in the cancellous bone, thereby preventing bone loss. These findings underscore the importance of patient-specific stem design for improving implant stability and clinical outcomes.

Differences in Time to Return to Work Between Patients Undergoing Staged Versus Simultaneous Bilateral Total Hip Arthroplasty

BACKGROUND

Patients who undergo total hip arthroplasty (THA) oftentimes have severe osteoarthritis in both hips and may consider staged or simultaneous bilateral THA (bTHA). The goal of this study was to compare the total workdays missed following staged and simultaneous bTHA performed via either postero-lateral (PA) or direct anterior approach (DAA).

METHODS

Patients who were (1) employed, (2) underwent a staged (within 12 months) or simultaneous bTHA at our institution between February 1, 2016, and December 31, 2021, (3) completed a return-to-work questionnaire, and (4) had the same surgical approach for both THAs were included. The primary outcome of interest was the total days of work missed.

RESULTS

We identified 78 employed patients who had undergone staged bTHA (62 PA, 16 DAA) and 76 patients (44 PA, 32 DAA) who underwent simultaneous bTHA, and had completed the return-to-work questionnaire. Simultaneous bTHA patients missed an average of 25.6 days of work (SD: 14.3 days) compared to staged bTHA patients, who missed an average of 36.9 days of work (SD: 23.4) when combining days missed from both operations (P < 0.001). In multivariate mixed regression analysis adjusted for sex, age, body mass index, American Society of Anesthesiologists status, type of work, and surgical approach, the staged bTHA group missed a mean of 8.2 more days of work (SD: 3.3) compared to the simultaneous bTHA group (95% confidence interval: 1.8 to 14.7, P = 0.013).

CONCLUSIONS

Employed patients who underwent simultaneous bTHA missed an average of 8.2 fewer days of work compared to those who were treated with staged bTHA. These findings may help surgeons counsel their employed patients who have bilateral hip osteoarthritis and are considering surgical treatment.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Short-Term (90 Days) Clinical Outcomes Following the Day of Surgery Conversion of Inpatient to Same-Day Hip and Knee Arthroplasty

BACKGROUND

The incidence of total joint arthroplasty is increasing, with added emphasis on shifting care toward outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion.

METHODS

We identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a 2-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including reoperation, readmission, and emergency room visits within a 90-day postoperative period.

RESULTS

We identified a total of 80 patients who converted from inpatient to outpatient surgery over a 2-year interval. Over the first 90 days postoperatively 4 (5%) patients were readmitted: 2 (2.5%) for medical complications and 2 (2.5%) for reoperation. There were 2 (2.5%) reoperations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were 5 (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of 5 (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission.

CONCLUSIONS

Hospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.

Perioperative systemic corticosteroids in primary unilateral total knee arthroplasty: a systematic review

Main reasons for prolonged hospital stay after total knee arthroplasty (TKA) are postoperative nausea and vomiting (PONV) and pain. Having a positive effect on both PONV and pain, perioperative administration of corticosteroids might improve rehabilitation and reduce length of hospital stay (LOS) after TKA. Aim of this review is to determine the effect of different corticosteroid dosages on PONV, pain, and LOS in TKA. A systematic search for articles comparing dosage effects of corticosteroids regarding PONV, pain, and LOS after primary unilateral TKA was conducted using EMBASE, PubMed publisher, MEDLINE, Cochrane, Google scholar, and Web-of-Science for articles published from inception to March 17, 2022. 16 studies were included involving 2352 TKA procedures. Most studies showed reduced pain scores in corticosteroid groups and some described better pain reduction in high-dose groups. All studies showed reduced PONV in the corticosteroid groups. LOS was similar in most studies comparing placebo and perioperative corticosteroids. Only one study reported increased infection rates and intramuscular venous thrombosis in the corticosteroid group. Concluding, current literature on corticosteroids use in TKA is highly variable in type, dosage, and timing of administering medication. Overall, corticosteroids mostly reduce pain and PONV with limited effects on LOS after TKA. Only minimal statistically significant and clinically relevant benefits were found in perioperative high-dose corticosteroids compared to low-dose. Given the short follow-up in most studies, it is not possible to evaluate safety of high-dose corticosteroids.

Collared versus collarless hydroxyapatite-coated stems for primary cementless total hip arthroplasty; a systematic review of comparative studies. Is there any difference in survival, functional, and radiographic outcomes?

INTRODUCTION

This systematic review aims to critically assess the literature comparative studies investigating collared and collarless Corail stem in primary total hip arthroplasty (THA) to find differences in revision rates, radiographic and clinical outcomes, and postoperative complications between these two types of the same stem.

METHODS

Eligible studies were found by searching PubMed, Science Direct/Scopus, and the Cochrane Database of Systematic Reviews from conception till May 2023. The PRISMA guidelines were followed. The investigation encompassed randomized controlled trials, case series, comparative, cohort, and observational studies that assessed at least one comparative outcome or complication between collared and collarless Corail stems.

RESULTS

Twelve comparative studies with 90,626 patients undergoing primary THA were included. There were 40,441 collared and 58,543 collarless stems. The follow-up ranged from 12 to 360 months. Our study demonstrated no significant difference in stem revision relative risk (RR = 0.68; 95% confidence interval (CI), 0.23, 2.02; p = 0.49), number of radiolucent lines (RR = 0.3; 95% CI, 0.06, 2.28; p = 0.29) and overall complication risk (RR = 0.62; 95% CI, 0.22, 1.76; p = 0.37) between collared and collarless stems. The collared stems demonstrated significantly lesser subsidence (mean difference: 1.01 mm; 95% CI, -1.77, -0.25; p = 0.009) and risk of periprosthetic fractures (RR = 0.52; 95% CI, 0.29, 0.92; p = 0.03).

CONCLUSION

The comparative studies between collared and collarless stem groups showed similar survival and overall complication rates and functional outcomes. The similar revision rates between groups make the impact of higher subsidence for collarless stems uncertain. The lower risk of periprosthetic fractures in the collared stems group must be clarified further but could be related to increased rotational stability.

Comparison of three different prophylactic treatments for postoperative nausea and vomiting after total joint arthroplasty under general anesthesia: a randomized clinical trial

BACKGROUND

Postoperative nausea and vomiting (PONV) after total joint arthroplasty is common and associated with delayed recovery. This study was performed to evaluate the efficacy of three different prophylactic regimens for PONV after total joint arthroplasty under general anesthesia.

METHODS

Patients undergoing primary total hip or knee arthroplasty were randomized to Group A (ondansetron), Group B (10 mg dexamethasone plus ondansetron and mosapride), or Group C (three doses of 10 mg dexamethasone plus ondansetron and mosapride). The primary outcome was the total incidence of PONV during postoperative 48 h. The secondary outcomes were complete response, rescue antiemetic treatment, opioid consumption, time until first defecation, postoperative appetite score, satisfaction score, length of hospital stay, blood glucose level, and complications.

RESULTS

Patients in Group C experienced a lower incidence of total PONV (29.3%, p = 0.001) and a higher incidence of complete response (70.7%, p = 0.001) than did patients in Group A (51.9%, 48.2%, respectively). Patients in Group C also experienced a lower incidence of severe PONV (4.3%) than patients in Group A (25.9%, p<0.001) and B (20.4%, p<0.001). Moreover, less rescue antiemetic treatment (1.4 ± 0.5 mg Metoclopramide) and postoperative opioid consumption (1.8 ± 0.3 mg Oxycodone, 6.0 ± 1.0 mg Pethidine) was needed in Group C. Additionally, a shorter time until first defecation, shorter length of stay, and better postoperative appetite scores and satisfaction scores were detected in patients in Group C. A slight increase in the fasting blood glucose level was observed in Group C, and the complications were comparable among the groups.

CONCLUSION

Combined use of ondansetron, mosapride and three doses of dexamethasone can provide better antiemetic effectiveness, postoperative appetite, bowel function recovery, and pain relief than a single dose or ondansetron only.

TRIAL REGISTRATION INFORMATION

The protocol was registered at the Chinese Clinical Trial Registry (ChiCTR1800015896, April 27, 2018).

Direct anterior approach versus posterolateral approach for total hip arthroplasty in the treatment of femoral neck fractures in elderly patients: a meta-analysis and systematic review

OBJECTIVE

The purpose of this meta-analysis was to evaluate the postoperative clinical outcomes of elderly patients who underwent the direct anterior approach (DAA) versus those who received posterolateral approach (PLA) for total hip arthroplasty (THA) in the treatment of femoral neck fractures.

METHODS

An electronic search was conducted in databases including PubMed, Embase, Web of Science, the Cochrane Library, and CNKI from their inception to January 2022. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of DAA compared to PLA for the management of total hip arthroplasty (THA) in elderly patients using the dichotomous or continuous method with a random or fixed-effect model.

RESULTS

15 studies involving 1284 patients were included; 640 patients receiving DAA and 644 patients receiving PLA. DAA had a longer surgery duration than PLA [WMD = 9.41, 95% CI (4.64, 14.19), I2=95.5%]; The amount of postoperative drainage [WMD= -3.88, 95% CI (-5.59, -2.17), I2=98.3%], length of incision [WMD= -3.88, 95% CI (-5.59, -2.17), I2=98.3%], blood loss [WMD= -3.88, 95% CI (-5.59, -2.17), I2=98.3%], hospitalization time [WMD= -3.88, 95% CI (-5.59, -2.17), I2=98.3%], and postoperative bedtime [WMD = -5.56,95% CI (-7.11, -4.01), I2=99.0%], were similar between the two groups (p < 0.05). The HHS at 1 month, 12 months postoperatively [WMD = 7.58, 95%CI (5.70,9.46), I2=89.5%; WMD= 2.56, 95%CI 0.11,5.00, I2=93.2%] and the incidence of LFCN in patients were higher in the DAA group (OR = 2.91, 95% CI 1.26 to 6.71, I2=0.0%), while fewer patients in the DAA group suffered from postoperative dislocation than in the PLA group (OR = 0.26, 95% CI 0.11 to 0.60, I2=0.0%). No significant difference was observed in HHS at 1 week, 3 months, and 6 months postoperatively, VAS postoperatively at each time point, acetabular anteversion angle, acetabular abduction angle, wound infection, deep vein thrombosis, and intraoperative fracture (p > 0.05).

CONCLUSIONS

DAA offers a quicker functional recovery and is less invasive with an earlier return to daily activities in older THA patients than PLA. However, DAA was found to be associated with a high incidence of lateral femoral cutaneous nerve injury and a low incidence of postoperative dislocation.Key messagesThe present study aims to evaluate the clinical outcomes in elderly patients receiving DAA versus PLA for THA in the treatment of femoral neck fractures by mate-analysis.DAA offers a quicker functional recovery and is less invasive with an earlier return to daily activities in older THA patients. No significant difference was observed between the colchicine and comparators in terms of the need for HHS at 1 week, 3 months, and 6 months postoperatively, VAS postoperatively, acetabular anteversion angle, acetabular abduction angle, and complications (wound infection, deep vein thrombosis, and intraoperative fracture).

Is particulate or non-particulate steroid the determinant of periarticular injection efficacy for controlling postoperative TKR pain? Network meta-analysis

Purpose

Combining steroids for a periarticular injection (PAI) regiment has resulted in better pain control for postoperative TKR pain. Despite the available evidence, the most effective type of steroid for PAI still needs to be established. Network meta-analysis is conducted to analyze whether there is any difference in the effect of particulate compared to non-particulate periarticular steroid injection on post-TKR patients for pain control based on published literature.

Method

This study is conducted following the PRISMA guideline. In general, studies assessing the efficacy of periarticular injection analgesia added with either particulate (Triamcinolone, methylprednisolone, or prednisolone) or non-particulate (dexamethasone or betamethasone) steroid compared to the same regiment were analyzed.

Results

Ten studies were finally included from the 108 identified papers through database searching. VAS reduction on POD1 is found to be similar in particulate (0,91; CI95%: 0,45-1,37) compared to non-particulate (0,81; CI95%: 0,34-1,28) (Fig. 2). The difference becomes wider and favors non-particulate POD3. Subgroup analysis based on each steroid type was conducted. A stark difference can be observed for each pair of steroids (particulate and non-particulate), resulting in a similar cumulative effect of particulate and non-particulate steroids and inconsistent result on POD1 compared to POD3.

Conclusion

From the available evidence, we concluded that particulate or non-particulate steroid does not significantly affect post-TKR pain management. Instead, the specific type of steroid contributes more to postoperative VAS reduction.

Levels of evidence

Level III.

Association of Total Knee Replacement Removal From the Inpatient-Only List With Outpatient Surgery Utilization and Outcomes in Medicare Patients

Importance

Little is known about the association of total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 with outcomes in Medicare patients.

Objective

To evaluate (1) patient factors associated with outpatient TKR use and (2) whether the IPO policy was associated with changes in postoperative outcomes for patients undergoing TKR.

Design, Setting, and Participants

This cohort study included data from administrative claims from the New York Statewide Planning and Research Cooperative System. Included patients were Medicare fee-for-service beneficiaries undergoing TKRs or total hip replacements (THRs) in New York State from 2016 to 2019. Multivariable generalized linear mixed models were used to identify patient factors associated with outpatient TKR use, and with a difference-in-differences strategy to examine association of the IPO policy with post-TKR outcomes relative to post-THR outcomes in Medicare patients. Data analysis was performed from 2021 to 2022.

Exposures

IPO policy implementation in 2018.

Main Outcomes and Measures

Use of outpatient or inpatient TKR; secondary outcomes included 30-day and 90-day readmissions, 30-day and 90-day postoperative emergency department visits, non-home discharge, and total cost of the surgical encounter.

Results

A total of 37 588 TKR procedures were performed on 18 819 patients from 2016 to 2019, with 1684 outpatient TKR procedures from 2018 to 2019 (mean [SD] age, 73.8 [5.9] years; 12 240 female [65.0%]; 823 Hispanic [4.4%], 982 non-Hispanic Black [5.2%], 15 714 non-Hispanic White [83.5%]). Older (eg, age 75 years vs 65 years: adjusted difference, -1.65%; 95% CI, -2.31% to -0.99%), Black (-1.44%; 95% CI, -2.81% to -0.07%), and female patients (-0.91%; 95% CI, -1.52% to -0.29%), as well as patients treated in safety-net hospitals (disproportionate share hospital payments quartile 4: -18.09%; 95% CI, -31.81% to -4.36%), were less likely to undergo outpatient TKR. After IPO policy implementation in the TKR cohort, there were lower adjusted 30-day readmissions (adjusted difference [AD], -2.11%; 95% CI, -2.73% to -1.48%; P < .001), 90-day readmissions ( -3.23%; 95% CI, -4.04% to -2.42%; P < .001), 30-day ED visits ( -2.45%; 95% CI, -3.17% to -1.72%; P < .001), 90-day ED visits (-4.01%; 95% CI, -4.91% to -3.11%; P < .001) and higher cost per encounter ($2988; 95% CI, $415 to $5561; P = .03). However, these changes did not differ from changes in the THR cohort except for increased TKR cost of $770 per encounter ($770; 95% CI, $83 to $1457; P = .03) relative to THR.

Conclusions and Relevance

In this cohort study of patients undergoing TKR and THR, we found that older, Black, and female patients and patients treated in safety-net hospitals may have had lesser access to outpatient TKRs highlighting concerns of disparities. IPO policy was not associated with changes in overall health care use or outcomes after TKR, except for an increase of $770 per TKR encounter.

Management of perioperative pain after TKA

Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.

Outcomes and Cost Analysis of a Surgical Care Unit for Outpatient Total Joint Arthroplasties Performed at a Tertiary Academic Center

Background

Methods

Results

Conclusions

Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors

Aims

The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.

Methods

This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m². Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression.

Results

In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m² (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD.

Conclusion

SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology.

Cite this article: Bone Jt Open 2022;3(9):684–691.

Same-day discharge after early mobilisation and increased frequency of physiotherapy following hip and knee arthroplasty

Background

Advanced rehabilitation pathway (ARP) after hip and knee arthroplasties is popular globally and is gaining ground in South Africa (SA). A multidisciplinary team in Rustenburg, SA, has implemented an ARP with the first same-day discharge (SDD) from hospital. The lack of evidence of physiotherapy protocols within an ARP determined our study.

Objectives

Determine and compare hospital length of stay (LOS) (hours), patient satisfaction (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), patient safety (30-day re-admission) and cost between the two cohorts.

Method

A quantitative prospective patient (treatment) group receiving early mobilisation with increased frequency of physiotherapy on post-operative day zero (POD0) was compared to a conservatively managed retrospective historical (control) group following post-operative elective hip and knee arthroplasties.

Results

Results for the prospective group which were significantly improved relative to the retrospective group included decreased LOS (median 7.650, p < 0.001), less pain at 6 weeks (mean 16.20, standard deviation [SD] = 2.673, p < 0.001), less stiffness (mean 5.82, SD = 1.214, p = 0.007), higher function (mean 54.87, SD = 8.544, p < 0.001), lower hospital cost (mean R43 340, p < 0.001) and physiotherapy cost (mean R1069, p < 0.001), and total costs compared to the retrospective group (mean R117 062, p < 0.001).

Conclusion

Safe and cost-effective SDD is possible in an ARP with earlier mobilisation and increased frequency of physiotherapy on POD0.

Clinical implications

Achieving safe SDD after hip and knee arthroplasty surgeries saved costs and improved patient satisfaction, with a decrease in LOS being beneficial for medical funders and stakeholders including government aiming to implement National Health Insurance (NHI) in the future.

Centers for Medicare & Medicaid Services' 2018 Removal of Total Knee Arthroplasty From the Inpatient-only List Led to Broad Changes in Hospital Length of Stays

INTRODUCTION

Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the "inpatient-only" list from January 1, 2018. The impact of this change on actual hospital length of stay (LOS) and patient coding is of interest.

METHODS

Patients undergoing TKA were abstracted from the 2015 to 2018 National Surgical Quality Improvement Program database. Patient characterization as "inpatient" or "outpatient" and actual LOS were assessed. Ordinal and categorical data comparisons were done with Pearson chi-squared tests. Continuous variables were tested for normality, and nonparametric analyses were conducted using the Mann-Whitney test. Significance was set at P < 0.05.

RESULTS

In total, 125,613 TKA patients from 2017 to 2018 were identified (232,269 TKA patients from 2015 to 2018). Most patients undergoing TKA were of Medicare eligibility (≥65 years old; 60.78% in 2017 and 62.42% in 2018). Overall, LOS decreased significantly from 2017 to 2018 (2.31 ± 1.56 days versus 2.05 ± 1.57 days; P < 0.001), and more patients were discharged the same day (5.09% versus 2.28%; P < 0.001). In 2017, patients were coded as "outpatient" 1.66% of the time (those with LOS = 0 days were 22.85%, LOS = 1 day were 1.80%, LOS = 2 days were 0.79%, and LOS ≥3 days were 0.85%). In 2018, patients were coded as "outpatient" 17.14% of the time (those with LOS = 0 days were 78.2%, LOS = 1 day were 29.75%, LOS = 2 days were 6.96%, and LOS ≥3 days were 3.05%). This represented a significant change for each LOS day (P < 0.001). These results remained true when stratifying by Medicare eligibility (P < 0.001 for those <65 years old and those ≥65 years old).

DISCUSSION

After the 2018 removal of TKA from the CMS "inpatient-only" list, patients were more likely to be discharged the same day and be considered "outpatients." Patients with more prolonged LOS and those younger than 65 years were more likely to have been coded as "outpatient" in 2018 compared with 2017. These data demonstrate that national changes in CMS policies can have broad impact on overall practice patterns.

LEVEL OF EVIDENCE

Retrospective cohort study.

Physiotherapy in an advanced rehabilitation pathway for patients after hip and knee arthroplasty: A proposal

Background

Accelerated rehabilitation pathway (ARP) decrease patients’ hospital length of stay (LOS). A lack of evidence exists on physiotherapy management and outcome as part of ARP in South Africa (SA). Our study will aim to determine whether early mobilisation and increased frequency of physiotherapy treatments for participants after hip or knee arthroplasty surgery on post-operative day 0 (POD 0) affect outcome.

Methods/design

A quantitative prospective cohort study incorporating ARP on (n = 60) non-randomised elective hip and knee arthroplasty participants will be compared with a more conservatively managed historical control group (n = 60). The physiotherapy protocol includes early mobilisation and exercises 1–3 h post-operatively on POD 0 and a second mobilisation and exercise session, 1–2 h later. Outcomes measures are as follows: hours for LOS, the WOMAC measured pre-operatively, 6 weeks and 3 months post-operatively, 30-day readmission for safety and cost comparison between the prospective and historical cohorts. Descriptive statistics will be undertaken. A paired t-test will be used to analyse each of the outcome measures across the time periods if data are normally distributed. Length of stay, WOMAC score and cost data will be compared between the groups, using a Mann–Whitney U test. The occurrence of adverse events will be compared between the groups using Pearson’s chi-square tests. The confidence interval will be set at 95% and p = 0.05 will be considered statistically significant.

Discussion

Globally, ARP’s are successfully implemented to manage patients presenting with hip and knee osteoarthritis (OA). Research investigating physiotherapy protocols in an ARP is lacking in the literature.

Conclusion

Achieving the same-day discharge after hip and knee arthroplasty surgeries may help elective surgery backlogs and waiting lists in a more cost-effective manner.

Clinical implications

The same day discharge after arthroplasty may be a cost-effective management option in the future.

Protocol identification

Pan African Clinical Trial Registry, PACTR202103637993156.

Post-Operative Remote Monitoring for Same-Day Discharge Elective Orthopedic Surgery: A Pilot Study

The purposes of this pilot study are to utilize digital remote monitoring to (a) evaluate the usability and satisfaction of a wireless blood pressure (BP) and heart rate (HR) monitor and (b) determine whether these data can enable safe mobilization at home after same-day discharge (SDD) joint replacement. A population of 23 SDD patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) were given a cellular BP/HR monitor, with real-time data capture. Patients took three readings after surgery, observing for specific blood pressure decreases, HR increases, or hypotensive symptoms. If any criteria applied, patients followed a hydration protocol and delayed ambulation. Home coaching was also provided to each patient. Patient experience was surveyed, and responses were assessed using descriptive statistics. Of 18 patients discharged (78%), 17 returned surveys, of which 100% reported successful device operation. The mean "ease of use" rating was 8.9/10; satisfaction with home coaching was 9.7/10; and belief that the protocol improved patient safety was 8.4/10. A total of 27.8% (n = 5) had hypotensive readings and appropriately delayed ambulation. Our pilot findings support the feasibility of and confirm the satisfaction with remote monitoring after SDD arthroplasty. All patients with symptoms of hypotension were successfully remotely managed using a standardized hydration protocol prior to safe mobilization.

Differences in time to return to work among patients undergoing simultaneous versus staged bilateral total knee arthroplasty

AIMS

Many patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA.

METHODS

The prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA.

RESULTS

We identified 152 employed patients who had undergone simultaneous bilateral TKA and 61 who had undergone staged bilateral TKA, and had completed the registry's return to work questionnaire. The simultaneous group missed a mean of 46.2 days (SD 29.1) compared with the staged group who missed a mean total of 68.0 days of work (SD 46.1) when combining both operations. This difference was statistically significant (p < 0.001). In multivariate mixed regression analysis adjusted for age, sex, BMI, American Society of Anesthesiologists status, and type of work, the simultaneous group missed a mean of 16.9 (SD 5.7) fewer days of work compared with the staged group (95% confidence interval 5.8 to 28.1; p = 0.003).

CONCLUSION

Employed patients undergoing simultaneous bilateral TKA missed a mean of 17 fewer days of work as a result of their surgical treatment and rehabilitation compared with those undergoing staged bilateral TKA. This information may be useful to surgeons counselling employed patients with bilateral OA of the knee who are considering surgical treatment. Cite this article: Bone Joint J 2021;103-B(6 Supple A):108-112.

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study

BACKGROUND

The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle.

METHODS

This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education.

RESULTS

The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030).

CONCLUSION

Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle.

LEVEL OF EVIDENCE

Level III.

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study

BACKGROUND

Postoperative pain remains a major barrier to a patient's recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated. This study aims to evaluate any combination effect of both routes of corticosteroids in TKA.

METHODS

This is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids. For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS). Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient.

RESULTS

Forty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05). No differences in Southampton wound scores and functional knee scores for up to 1 year.

CONCLUSION

Combining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.

Oral mosapride can provide additional anti-emetic efficacy following total joint arthroplasty under general anesthesia: a randomized, double-blinded clinical trial

Background

We sought to determine (1) whether the addition of prophylactic oral mosapride to a protocol including dexamethasone and ondansetron further reduces postoperative nausea and vomiting (PONV) compared with ondansetron alone or the combination of both; (2) whether preemptive application of oral mosapride provides additional clinical benefits for bowel function and appetite, thus improving functional recovery.

Methods

We randomized 240 patients undergoing total hip and knee arthroplasty to receive placebo (Control, n = 80), dexamethasone (10 mg) before anesthesia induction (Dexa, n = 82), or dexamethasone (10 mg) before anesthesia induction as well as oral mosapride (5 mg) before and after surgery (Mosa+Dexa, n = 78). Patients were assessed at 0–6, 6–12, 12–24, and 24–48 h postoperatively. Primary outcomes were incidence and severity of PONV as well as complete response. Secondary outcomes were appetite, time until first defecation and ambulation, patient satisfaction score, and length of hospital stay.

Results

Mosa+Dexa patients showed significantly lower incidence of nausea at 6–12 h (3.8%) and over the entire evaluation period (6.4%), as well as a higher rate of complete response (89.7%) than other patients. Mosa+Dexa patients required less time to achieve first defecation and ambulation, they were hospitalized for shorter time, and they were more satisfied with clinical care.

Conclusion

Addition of oral mosapride further reduced incidence of PONV, especially postoperative nausea, during 6–12 h postoperatively. Moreover, preemptive application of oral mosapride can further improve appetite, bowel function, ambulation and length of hospital stay.

Trial registration

The study protocol was registered at the Chinese Clinical Trial Registry (ChiCTR1800015896), prospectively registered on 27/04/2018.

K-Means Clustering to Elucidate Vulnerable Subpopulations Among Medicare Patients Undergoing Total Joint Arthroplasty

BACKGROUND

The role of preoperative laboratory values for risk stratification following joint arthroplasty is currently ambiguous. In order to improve upon existing risk stratification within joint arthroplasty, this study sought to define novel phenotypes of total hip or total knee arthroplasty patients based entirely on preoperative laboratory measures. These phenotypes ("clusters") were compared to elucidate statistically and clinically significant differences in outcomes.

METHODS

A total of 134,252 patients were gathered from the National Surgical Quality Improvement Program database between 2005 and 2015. "K-means" with 3 clusters was applied using 9 preoperative laboratory values: sodium, blood urea nitrogen (BUN), creatinine, albumin, bilirubin, white blood cell count, hematocrit, platelet count, and international normalized ratio of prothrombin values (INR). Outcome measures included 30-day readmissions, severe adverse events, and discharge to nonhome.

RESULTS

Cluster 2 was characterized by elevated preoperative BUN, creatinine, and INR and demonstrated almost twice the rate of adverse events (3.52% vs 2.20% and 2.22%), 30-day readmissions (6.39% vs 3.31% and 3.71%), and discharge to nonhome (47.97% vs 30.50% and 35.85%). Cluster 3 was characterized by a slightly higher risk of discharge to nonhome than cluster 1 and was overwhelmingly female (79.5% female, 35.8% discharge to nonhome). Cluster 1 represents the lowest-risk subgroup, experiencing the lowest rates of readmissions, adverse events, and discharge to nonhome.

CONCLUSION

Preoperative laboratory values, namely BUN, creatinine, and INR, are useful in identifying patients at risk of adverse outcomes. This analysis supports the existing surgical literature pushing for preoperative hydration as a targeted intervention to expedite recovery.

Predictors of farther mobilization on day of surgery and shorter length of stay after total joint arthroplasty

BACKGROUND

Mobilization on the day of total joint arthroplasty (TJA) is associated with shorter length of stay. The question of whether incrementally farther mobilization on the day of surgery (POD0) contributes to shorter length of stay has not been widely studied. The purpose of this study was to determine if farther mobilization on POD0 led to shorter length of stay and to identify the predictors of farther mobilization and length of stay.

METHODS

A retrospective chart review was undertaken using data for patients who had a primary TJA and mobilized on POD0. Patients were categorized into the following 4 mobilization groups: sat on the bedside (Sat), stood by the bed or walked in place (Stood), walked in the room (Room) and walked in the hall (Hall). The primary outcome was length of stay. Predictors of farther mobilization on POD0 and length of stay were identified using regression analyses.

RESULTS

The sample comprised 283 patients. The Hall group had significantly shorter length of stay than all other groups. There were sex differences across the mobilization groups. Simultaneous regression analysis showed that farther mobilization was predicted by younger age, male sex, lower body mass index, spinal anesthesia and fewer symptoms limiting mobilization. Hierarchical regression showed that shorter length of stay was predicted by male sex, lower body mass index, lower American Society of Anaesthesiologists physical status classification score, less pain/stiffness and farther mobilization on POD0.

CONCLUSION

Understanding the modifiable and nonmodifiable predictors of mobilization after TJA and length of stay can help identify patients more likely to mobilize farther on the day of surgery, which would contribute to better resource allocation and discharge planning. Focusing on symptom management could increase opportunities for farther mobilization on POD0 and thereby decrease length of stay.

After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.

The Development of a Standardized Pathway for Outpatient Ambulatory Fracture Surgery: To Admit or Not to Admit

BACKGROUND

Increased scrutiny of health-care costs and inpatient length of stay has resulted in many orthopaedic procedures transitioning to outpatient settings. Recent studies have supported the safety and efficiency of outpatient fracture procedures. The aim of the present study was to reduce unnecessary inpatient hospitalizations for healthy patients awaiting surgical treatment of a fracture by 80% by June 30, 2017, with a focus on timely, efficient, and patient-centered care.

METHODS

The study design was a time series using statistical process control methodology. Baseline data from October 2014 to June 2016 were compared with the intervention period from July 2016 to December 2018. The Model for Improvement was used as the framework for developing and implementing interventions. The main interventions were a policy change to allow booking of outpatient urgent-room cases, education for patients and nurses, and the development of a standardized outpatient pathway.

RESULTS

One hundred and eighty-seven patients during the pre-intervention period and 308 patients during the intervention period were eligible for the ambulatory pathway. The percentage of patients managed as outpatients increased from 1.6% pre-intervention to 89.1% post-intervention. The length of stay was reduced from 2.8 to 0.2 days, a decrease of 94.0%. Patient satisfaction remained high, and there were no safety concerns while patients waited at home for the surgical procedure.

CONCLUSIONS

The outpatient fracture pathway vastly improved the efficiency and timeliness of care and reduced health-care costs. A patient-centered culture and support from hospital administration were integral in producing sustainable improvement.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are Continuous Femoral Nerve Catheters Beneficial for Pain Management After Operative Fixation of Tibial Plateau Fractures? A Randomized Controlled Trial

OBJECTIVE

To determine whether a continuous femoral nerve block after open reduction internal fixation of tibial plateau fractures would diminish Visual Analog Scale (VAS) scores and/or systemic narcotic intake.

DESIGN

Randomized controlled trial.

SETTING

Level 1 academic trauma center.

PATIENTS

Forty-two consecutive patients with operatively treated tibial plateau fractures.

INTERVENTION

Continuous femoral nerve catheter for postoperative pain management was performed in the experimental group.

MAIN OUTCOME MEASURES

Both the VAS scores for pain and narcotic intake were assessed at 4, 8, 12, 24, 36, 48, and 72 hours postoperatively.

RESULTS

Forty-two patients were enrolled in this study. There were 21 women and 21 men 21-70 years of age (avg 49) with operatively treated tibial plateau fractures. Twenty-one patients were randomized to receive a femoral nerve block with 5 crossovers for technical reasons. Accordingly, we analyzed 16 patients with femoral nerve blocks and 26 with standard care. There were no significant differences between the study groups regarding age, sex, or fracture type. There was no significant difference in VAS scores between the control and experimental group at any time point. The total systemic morphine equivalent for the femoral nerve block group and the control group was 375 and 397 respectively (P = 0.76). Across groups, patients with bicondylar fractures tended to have higher VAS than those with unicondylar fractures and to use more narcotics, although neither was statistically significant.

CONCLUSION

Femoral nerve blocks for postoperative pain management in tibial plateau fractures did not demonstrate an improvement in pain relief or narcotic use.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

An evidence-based review of enhanced recovery after surgery in total knee replacement surgery

Rationale: Enhanced recovery after surgery is gaining popularity among orthopaedic surgeons across the globe and hence a strong evidence base had to be reviewed to make an evidence-based sustainable protocol.

Methods

The following databases, PubMed, OVID, Cochrane database and EMBASE were searched. The search was limited to 15 components of enhanced recovery after surgery programme which is divided into preoperative, intraoperative and postoperative phases. Inclusion criteria were restricted to articles published in English within the last 15 years and articles comprising of unicompartmental arthroplasty, revision knee arthroplasty, bilateral simultaneous knee arthroplasty and only hip arthroplasty excluded. The full texts were analysed and controversies and limitations of various studies were summarised.

Discussion

Each component of the programme was thoroughly reviewed and strength and weaknesses of the evidence base summarised. The strength of the evidence was assessed by critically appraising the study methodology and justifying the appropriateness of the inclusion in enhanced recovery after surgery protocol.

Conclusion

Enhanced recovery after surgery has already been used successfully in various surgical specialities. Enhanced recovery after surgery programmes in knee arthroplasty are yet to be established as a universal practice to be adopted globally. This evidence-based review provides an insight into the best evidence linked to each component and their rationale for inclusion in the proposed enhanced recovery after surgery protocol.

The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials

Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.

Total Knee Arthroplasty Is Safe and Successful in Patients With Klippel-Trénaunay Syndrome

BACKGROUND

Klippel-Trénaunay syndrome (KTS) is a severe vascular malformation that can lead to hypertrophic osteoarthritis. Total knee arthroplasty (TKA) performed in extremities affected with KTS is challenging given the high-risk vascular considerations and occasionally poor bone quality.

METHODS

We identified 12 patients with KTS who underwent TKA between 1998 and 2017. There were 7 men, mean age 42 years, and mean follow-up was 7 years. Before arthroplasty, 2 patients (17%) had preoperative sclerotherapy. Preoperative vascular studies were done for 9 patients (75%) and included magnetic resonance imaging (n = 7), magnetic resonance angiography (n = 1), and computed tomography angiography (n = 1). A preoperative blood conservation protocol was used for all operations and included the use of tranexamic acid (TXA) in later years. Posterior-stabilized TKA was used in 10 cases and cruciate-retaining TKA was used in 2 cases.

RESULTS

At final follow-up, 2 patients (17%) had undergone revision surgery: 1 for infection and 1 for tibial loosening with subsequent arthrofibrosis. Knee Society Scores (36-83, P < .0001) and functional scores (48-84, P = .0007) significantly increased between the preoperative and postoperative period. Likewise at last follow-up, the mean knee range of motion significantly increased (82°-104°, P = .04). Median blood loss for patients who received TXA was 200 mL compared to 275 mL in patients who did not receive TXA (P = .66). Likewise there was no difference (P = .5) in the proportion of patients who required a transfusion between those who received TXA (2/6, 33%) and those who did not (3/6, 50%).

CONCLUSION

In this small series, TKA can lead to significant clinical improvement for patients with KTS. Modern blood management techniques and a careful multidisciplinary care approach render TKA a reasonable option for select patients with KTS.

LEVEL OF EVIDENCE

Level IV case series, therapeutic.

A retrospective analysis of the use of intravenous dexamethasone for postoperative nausea and vomiting in total joint replacement

Background

Multimodal perioperative pain-management protocols have contributed to the success of elective total joint replacement in orthopedic surgery. General or neuraxial anesthesia for arthroplasty is accompanied by complications such as pruritis, nausea, and vomiting. Dexamethasone has been demonstrated to be a safe perioperative antiemetic. This study evaluates the benefit of low-dose intravenous dexamethasone used in the perioperative period to prevent postoperative nausea and vomiting.

Methods

Two scheduled doses of 8 mg of dexamethasone 12 hours apart after total hip arthroplasty or total knee arthroplasty were given to a dexamethasone group (n = 492) and were retrospectively compared with a no-dexamethasone group (n = 364) based on the use of antiemetics in the postoperative period. Frequency of antiemetic use in both groups was compared using a zero-inflated fixed-model Poisson distribution. Additional analysis included need for opioid analgesic, administration of diphenhydramine, and postoperative infection rates at 30 and 90 days.

Results

The dexamethasone group was found to have a significant reduction in need for the rescue antiemetic ondansetron (P = .00194). There was an associated reduction in length of stay for the treatment group (mean 1.83 days) relative to the control group (mean 2.17 days) (P < .001). There was no significant difference in postoperative infection rates at 30 or 90 days after arthroplasty.

Conclusions

Dexamethasone is a safe adjunct to perioperative protocol that may reduce nausea, thus improving patient satisfaction. There is an associated reduction in length of stay that may reduce cost of hospitalization.

Bone Cement Implantation Syndrome: Key Concepts for Perioperative Nurses

Bone cement implantation syndrome (BCIS) is a potentially fatal complication of orthopedic surgeries that use cement. The symptoms of BCIS occur primarily during femoral fracture repairs, but this complication has been reported in a wide variety of cemented procedures. Clinical presentation of this syndrome begins as a cascade with hypoxia and hypotension; if it is not reversed, it ends with right-sided heart failure and cardiac arrest. This syndrome usually occurs at cementation, prosthesis insertion, joint reduction, or tourniquet deflation, and should be treated with aggressive resuscitation and supportive care. This article provides a comprehensive explanation of bone cement, the identification and management of BCIS, and the roles of the perioperative team in the event of cardiopulmonary collapse. It includes a case study that can be used as an educational tool for simulation, mock drills, or staff meetings; it also may be used as a framework for creating policies.

Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: a case control study in 238 patients

Background

Dexamethasone has been routinely used in the pre-operative setting to enhance analgesia and decrease the incidence of nausea and vomiting in patients undergoing primary arthroplasty. However, dexamethasone has the potential to increase blood glucose levels postoperatively, which is a known risk factor for complications after total joint arthroplasty. The aim of this study was to analyze the effect of dexamethasone administration on post-operative blood glucose levels in diabetic patients after primary hip and knee arthroplasty.

Methods

This study was a retrospective review of 238 diabetic patients who underwent primary hip and knee arthroplasty between May 1, 2014 and September 30, 2016 at a single urban academic medical center. A total of 77 patients (32.4%) received dexamethasone and 161 (67.7%) did not. Oral hyperglycemic agents were held during the inpatient stay and blood glucose was controlled either with sliding scale insulin or home insulin regimens were continued. All analyses were adjusted for age, BMI, gender, type of diabetes, pre-operative diabetic medication, type of surgical procedure, and pre-operative HgbA1c level. The primary outcome was post-operative hyperglycemia within 72 h of surgery defined as any blood glucose level greater than or equal to 200 mg/dL.

Results

Post-operative hyperglycemia was observed in 17.1 and 20.6% of the measurements during the first 24 and 72 h respectively. After controlling for confounding variables, patients who received dexamethasone had 4.07 (95% CI: 2.46, 6.72) and 3.08 (95% CI: 2.34, 4.04) higher odds of post-operative hyperglycemia in the first 24 and 72 h respectively.

Conclusions

Dexamethasone administration in diabetic patients undergoing primary arthroplasty increases post-operative hyperglycemia during the first 24 and 72 h. While our data did not investigate causation, dexamethasone use in this patient population should be thoughtfully considered, as post-operative hyperglycemia is a known risk factor for complications.

The Opioid Crisis and the Orthopedic Surgeon

Opioid use and abuse has become a national crisis in the United States. Many opioid abusers become addicted through an initial course of legal, physician-prescribed medications. Consequently, there has been increased pressure on medical care providers to be better stewards of these medications. In orthopedic surgery and total joint arthroplasty, pain control after surgery is critical for restoring mobility and maintaining patient satisfaction in the early postoperative period. Before the opioid misuse epidemic, orthopedic surgeons were frequently influenced to "treat pain with pain medications." Long-acting opioids, such as OxyContin were used commonly. In the past decade, there has been a paradigm shift in favor of multimodal pain control with limited opioid use. This review will discuss 4 major topics. First, we will describe the pressures on orthopedic surgeons to prescribe narcotic pain medications. We will then discuss the major and minor complications and side effects associated with these prescriptions. Second, we will review how these factors motivated the development of alternative pain management strategies and a multimodal approach. Third, we will look at perioperative interventions that can reduce postoperative opioid consumption, including wound injections and peripheral nerve blocks, which have shown superb clinical results. Finally, we will recommend an evidence-based program that avoids parenteral narcotics and facilitates rapid discharge home without readmissions for pain-related complaints.

Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting

BACKGROUND

Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.

METHODS

In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.

RESULTS

After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).

CONCLUSION

In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Has Tranexamic Acid in Total Knee Arthroplasty Made Tourniquet Use Obsolete?

The application of tranexamic acid (TXA) in total joint arthroplasty has dramatically improved peri-operative blood management. In light of these benefits, a study by Huang et al., "Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty," evaluates the need for continued use of the intra-operative tourniquet, which remains a routine practice with documented benefits and adverse effects. This review evaluates the study's design and critically interprets its findings for clinical practice. Through a prospective, randomized trial, Huang et al. demonstrated that among selected patients undergoing primary total knee arthroplasty, the use of a tourniquet results in no reduction in blood loss beyond that provided by TXA alone. Moreover, the use of TXA without a tourniquet led to improved early clinical outcomes such as reduced post-operative swelling, improved knee range of motion at discharge, and enhanced patient satisfaction. As medicine is practiced in an increasingly value-driven environment, this study provides a useful method for evaluating the utility of commonly used interventions. Its findings highlight the need for future investigations into the optimal administration of TXA in total knee arthroplasty.

The efficacy of dexamethasone on pain and recovery after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total hip arthroplasty (THA) perioperative dexamethasone treatment is still a controversial subject. We write this systematic review and meta-analysis to evaluate the efficacy of dexamethasone on pain and recovery after THA.

METHODS

Two researchers searched the relevant studies from Pubmed, Cochrane, and Embase. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) were included in our meta-analysis. At the same time, the assessment of the risk of bias was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version. The pooled data are processed by software RevMan 5.3.

RESULT

In accordance with inclusion and exclusion, 3 studies with 207 patients were eligible and accepted into this meta-analysis. For RCTs, the risk of bias was evaluated by Cochrane Collaboration tool. Only one study did not have detection bias. Our study demonstrated that the dexamethasone group was more effective than the placebo group in term of visual analogue scale (VAS) score at 24 hours (P < .001), 48 hours (P = .04); opioid consumption (P < .001); length of stay (LOS, P < .001); and postoperative nausea (P = .001).

CONCLUSION

Dexamethasone not only reduces postoperative pain scores and postoperative opioids consumption within 48 hours, but also reduces postoperative vomiting and effectively reduces LOS. However, we still need large sample size and high quality studies to explore the relationship between complications and dose response to give the final conclusion.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly

There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.

Patient Perceptions Regarding Outpatient Hip and Knee Arthroplasties

BACKGROUND

There has been increasing interest in outpatient total joint arthroplasty (TJA) in the orthopedic community, but how patients feel about outpatient TJA is unknown. The purpose of this study was to understand patient perspectives on hip and knee replacements performed in an outpatient setting.

METHODS

We surveyed 110 consecutive patients scheduled for primary TJA in an academic suburban arthroplasty practice regarding their knowledge and perceptions of outpatient TJA. Questionnaires were administered during preoperative clinic visits before discussion of surgery location, length of stay, and before preoperative joint replacement education.

RESULTS

Fifty-seven percent of respondents were female, and 42.7% were aged 65 years or older. Very few patients expected same-day discharge (n = 3) or a one night stay in the hospital (n = 17). Fifty-four percent of patients were expected to stay in the hospital two or more nights. Only 54.5% of patients were aware that outpatient TJA is an option, with 55.3% of men and 31.7% of women reporting that they were comfortable with outpatient TJA (P = .030). In contrast, 61% and 72.8% believed that faster recovery and decreased likelihood of infection are likely advantages of outpatient TJA. Interestingly, 51.9% felt ambulatory surgery centers are as safe as hospitals, and 62.6% believed that home is the best place to recovery from TJA.

CONCLUSION

These observations suggest that there is need for patient education regarding outpatient TJA. As outpatient procedures become more common, it is essential that patients understand the ambulatory surgery process, the benefits and risks of same day discharge, and their role in a successful outpatient experience.

Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the "Outpatient Arthroplasty Risk Assessment Score"

BACKGROUND

Current patient selection criteria and medical risk stratification methods for outpatient primary total joint arthroplasty (TJA) surgery are unproven. This study assessed the predictive ability of a medically based risk assessment score in selecting patients for outpatient and short stay surgery.

METHODS

A retrospective review of 1120 consecutive primary TJAs in an early discharge program was performed. An Outpatient Arthroplasty Risk Assessment ("OARA") score was developed by a high-volume arthroplasty surgeon and perioperative internal medicine specialist to stratify patients as "low-moderate risk (≤59)" and "not appropriate" (≥60) for early discharge. OARA, American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and Charlson comorbidity index (CCI) scores were analyzed with respect to length of stay.

RESULTS

The positive predictive value of the OARA score was 81.6% for the same or the next day discharge, compared with that of 56.4% for ASA-PS (P < .001) and 70.3% for CCI (P = .002) scores. Patients with OARA scores ≤59 were 2.0 (95% confidence interval [CI], 1.4-2.8) times more likely to be discharged early than those with scores ≥60 (P < .001), while a low ASA-PS score was 1.7 (95% CI, 1.2-2.3) times more likely to be discharged early (P = .001). CCI did not predict early discharge (P ≥ .301). With deliberate patient education and expectations for outpatient discharge, the odds of early discharge predicted by the OARA score, but not the ASA-PS score, increased to 2.7 (95% CI, 1.7-4.2).

CONCLUSION

The OARA score for primary TJA has more precise predictive ability than the ASA-PS and CCI scores for the same or next day discharge and is enhanced with a robust patient education program to establish appropriate expectations for early discharge. Early results suggest that the OARA score can successfully facilitate appropriate patient selection for outpatient TJA, although consideration of clinical program maturity before adoption of the score is advised.

Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: a systematic review and meta-analysis of randomized trials

BACKGROUND

Perioperative systemic steroid administration for rapid recovery in total knee and hip arthroplasty (TKA/THA) is an important and controversial topic. We conducted this systematic review and meta-analysis to evaluate the overall benefits and harms of perioperative systemic steroid in patients undergoing TKA and THA.

METHODS

A comprehensive search was performed on PubMed, OVID, and Web of Science databases, and a systematic approach was carried out starting from the PRISMA recommendations. Relevant randomized controlled trials (RCTs) were selected. The risk of bias was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions version. Data were extracted and meta-analyzed or qualitatively synthesized for all the outcomes.

RESULTS

Data were extracted from 11 trials involving 774 procedures. Meta-analysis showed that high-dose systemic steroid (dexamethasone > 0.1 mg/kg) rather than low dose is effective to reduce postoperative nausea and vomiting and postoperative acute pain (within 24 h). In addition, systemic steroid is associated within faster functional rehabilitation and greater inflammation control. On the other hand, systemic steroid is associated with a higher level of postoperative serum glucose on the operation day. The complications between groups are similarly low.

CONCLUSIONS

Our study suggests that by providing lower incidence of postoperative nausea and vomiting and less postoperative acute pain, high-dose systemic steroid plays a critical role in rapid recovery to TKA and THA. The preliminary results also show the superior possibility of systemic steroid in functional rehabilitation and inflammation control. More large, high-quality studies that investigate the safety and dose-response relationship are necessary.

Effects of Modification of Pain Protocol on Incidence of Post Operative Nausea and Vomiting

Background:

A Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol.

Methods:

All total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions.

Results:

The incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols.

Conclusion:

Simple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed.

Perioperative Dexamethasone Administration Does Not Increase the Incidence of Postoperative Infection in Total Hip and Knee Arthroplasty: A Retrospective Analysis

BACKGROUND

Dexamethasone is frequently used for the treatment of postoperative nausea and vomiting and as an adjunct in multimodal postoperative analgesia after total joint arthroplasty; however, the incidence of periprosthetic joint infection (PJI) after the use of perioperative dexamethasone in total joint arthroplasty has yet to be fully elucidated.

METHODS

A retrospective chart review was conducted of all patients who underwent total hip or knee arthroplasty (N = 6294) between January 1, 2002 and January 31, 2014. The primary outcome was PJI requiring surgical intervention. Patients were subdivided into 2 cohorts; patients who received perioperative dexamethasone, a single 4- to 10-mg intravenous dose, as prophylaxis against postoperative nausea and vomiting (Dex group; N = 557) and those that did not receive perioperative dexamethasone (No Dex group; N = 5737). Secondary measures included timing of infection, culture data, and the type and number of subsequent procedures. Statistical analysis was performed using a chi-square or Fisher's exact test where appropriate.

RESULTS

Seventy-four joints of the 6294 joints included in this analysis ultimately developed a PJI for an overall incidence of infection of 1.2%. Seven of the 557 joints (1.3%) in the Dex group developed a PJI; 67 of the 5737 joints (1.2%) in the No Dex group developed an infection. This difference was not significant (P = .8022). No significant difference in the timing of infection or the number of subsequent procedures was seen.

CONCLUSION

A single intravenous perioperative dose of dexamethasone had no statistically significant difference in the rate of PJI after total hip or knee arthroplasty.