Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database

Racial and Ethnic Disparities in Primary Total Knee Arthroplasty Outcomes: A Systematic Review and Meta-Analysis of Two Decades of Research

Racial disparities in outcomes following total knee arthroplasty (TKA) remain persistent. This systematic review and meta-analysis aims to comprehensively synthesize data between 2000-2020. An electronic search of studies was performed on PubMed, SCOPUS, and the Cochrane Library databases from January 1, 2000, and December 31, 2020. Random effects models were used to report unadjusted and adjusted estimates for a comprehensive list of care outcomes in TKA. 63 studies met PRISMA criteria. Black patients report greater odds of in-hospital mortality (odds ratio [OR]: 1.37, 95% CI: 1.00-1.59 (p = 0.049); adjusted OR [aOR]: 1.34, 95% CI: 1.09-1.64), in-hospital complications (OR: 1.31, 95% CI: 1.27-1.35), 30-day complications (aOR: 1.19, 95% CI: 1.07-1.33), infection (OR: 1.11, 95% CI: 1.07-1.16; aOR: 1.30, 95% CI: 1.16-1.46), bleeding (OR: 1.33, 95% CI: 1.03-1.71; aOR: 1.47, 95% CI: 1.23-1.75), peripheral vascular events (PVE) (aOR: 1.46, 95% CI: 1.11-1.92), length of stay (LOS) (OR: 1.20, 95% CI: 1.08-1.34), extended-LOS (aOR: 1.89, 95% CI: 1.53-2.33), discharge disposition (OR: 1.59, 95% CI: 1.29-1.96; aOR: 1.96, 95% CI: 1.70-2.25), 30-day (OR: 1.20, 95% CI: 1.13-1.27; aOR: 1.17 95% CI: 1.09-1.26) and 90-day (OR: 1.46, 95% CI: 1.17-1.82) readmission compared to White patients. Disparities in bleeding, extended-LOS, discharge disposition, PVE, and 30-day readmission were observed in Asian patients. Hispanic patients experienced disparities in extended LOS and discharge disposition, while Native-American patients had disparities in bleeding outcomes. Persistent racial disparities in TKA outcomes highlight a need for standardized outcome measures and comprehensive data collection across multiple racial groups to ensure greater healthy equity.

Analysis of Costs Associated With Increased Length of Stay After Total Joint Arthroplasty at a Single Private Practice

INTRODUCTION

As the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) increases, so does the financial burden of these services. Despite efforts to optimize spending and bundled care payments, THA and TKA costs still need to be assessed. Our study explores the relationship between perioperative costs and length of stay (LOS) for THA and TKA.

METHODS

A total of 614 patients undergoing THA or TKA at a single private practice with LOS from zero to 3 days were identified. All patients were insured by private or Medicare Advantage insurance from a single provider. Primary outcomes included total costs and their relationship with LOS, classified into surgeon reimbursement, facility costs, and anesthesia costs. Secondary outcomes included readmission rates and discharge disposition. Analyses involved Student t-test, analysis of variance, and chi-square tests.

RESULTS

Longer LOS was associated with increased total, facility, and anesthesia costs. Costs for THA patients were stable except for reduced surgeon reimbursement with longer LOS. Patients undergoing TKA experienced an increase in facility costs with longer LOS. Total facility and anesthesia costs increased with LOS for Medicare Advantage patients, but surgeon reimbursement remained stable. Privately insured patients experienced higher total and facility costs but stable surgeon reimbursement and anesthesia costs regardless of LOS.

CONCLUSION

Our study shows an increase in total cost with longer LOS, especially pronounced in privately insured patients. A notable reduction was observed in the surgeon reimbursement for Medicare Advantage patients with extended LOS. These findings underscore the need for efficient surgical practices and postoperative care strategies to optimize hospital stays and control costs.

Biopsychosocial complexity in patients scheduled for elective TKA surgery: A feasibility pilot study with the INTERMED self-assessment questionnaire

OBJECTIVE

Primary aim; to determine the feasibility of implementation of the INTERMED Self-Assessment (IM-SA) in adult patients scheduled for total knee arthroplasty (TKA). Secondary aim; to measure biopsychosocial complexity, referral to psychiatry or psychology in cases of complexity and to gain insight into the relation between biopsychosocial complexity and length of stay (LOS), method of discharge (MOD) and polypharmacy.

METHODS

A feasibility study was conducted with 76 participants in a general hospital in the Netherlands. Feasibility was determined by the number of completed questionnaires, time spent completing the questionnaire and the attitude of staff and patients towards the IM-SA. A cut off point ≥19 on the IM-SA was used to determine the prevalence of biopsychosocial complexity. A case file study was performed to check if referral to psychiatry or psychology had taken place. The Spearman's Rank Correlation Coefficient or Phi was used to determine if there was a relation between biopsychosocial complexity and LOS, MOD and polypharmacy.

RESULTS

All participants completed the IM-SA. The average time spent completing the questionnaire was 11.46 min (SD 5.74). The attitude towards the IM-SA was positive. The prevalence of biopsychosocial complexity was 11.84%. Referral to psychiatry or psychology did not take place. There was no relation between complexity and LOS (Spearman's rho (r) = 0.079, p = 0.499, MOD (Phi = 0.169, p = 0.173) and polypharmacy (Phi = 0.007, p = 0.953).

CONCLUSION

Biopsychosocial complexity can be identified in TKA patients during the pre-operative phase by using the IM-SA. Implementation of the IM-SA in a Dutch general hospital is feasible.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis

BACKGROUND

As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort.

METHODS

A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission.

RESULTS

A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001).

CONCLUSION

There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

Impact of Sociodemographic and Hospital Factors on Inpatient Bilateral Reduction Mammaplasty: A National Inpatient Sample Analysis

Background

Although reduction mammaplasty remains a common procedure in plastic surgery, its interaction with sociodemographic and economic disparities has remained relatively uncharacterized on a nationwide scale.

Methods

Patients who underwent reduction mammaplasty were identified within the 2016-2018 National Inpatient Sample databases. In addition to clinical comorbidities, sociodemographic characteristics, hospital-level variables, and postoperative outcomes of each patient were collected for analysis. Statistical analyses, including univariate comparison and multivariate logistic regression, were applied to the cohort to determine significant predictors of adverse outcomes, described as extended length of stay, higher financial cost, and postoperative complications.

Results

The final patient cohort included 414 patients who underwent inpatient reduction mammaplasty. The average age was 45.2 ± 14.5 years. The average length of stay was 1.6 ± 1.5 days, and the average hospital charge was $53,873.81 ± $36,014.50. Sixty (14.5%) patients experienced at least one postoperative complication. Black race and treatment within a nonmetropolitan or rural county predicted postoperative complications (P < 0.01). Black race, lower relative income, and concurrent abdominal contouring procedures also predicted occurrence of extended length of stay (P < 0.01). Hospital factors, including larger bed capacity and for-profit ownership, predicted high hospital charges (P < 0.05). Severity of comorbidities, measured by a clinical index, also predicted all three outcomes (P < 0.001).

Conclusion

In addition to well-described clinical variables, multiple sociodemographic and economic disparities affect outcomes in inpatient reduction mammaplasty.

Does Time Spent in the Post-Anesthesia Care Unit Affect Hospital Lengths of Stay following Primary Total Knee Arthroplasty?

Given the current healthcare economic environment, substantial efforts have been made to help streamline the in-hospital care for total knee arthroplasty (TKA) patients. While potential cost-reducing factors have been identified in the literature, analyses specifically considering post-anesthesia care unit (PACU) lengths of stay (LOS) are lacking. Therefore, the purpose of this study was to identify factors associated with (1) longer PACU LOS as well as (2) longer Hospital LOS. Prospectively collected TKA data from seven participating hospitals within a large health system were evaluated for patient demographics, body mass indices, Charlson Comorbidity Indices (CCI), surgeon volumes/training, admission types, anesthesia types, PACU LOS, and overall hospital LOS. Complete data was available for 1,690 patients (1,082 females, mean age: 67 years). Univariate and multivariate analytical models were constructed to identify which factors were predictive of longer PACU and overall hospital LOS. Same-day admissions, higher volume surgeons (≥ 100 cases per year), fellowship-trained arthroplasty surgeons, and longer operative times were associated with longer PACU LOS (p < 0.05). Multivariate analyses found age more than or equal to 65 years (β= 0.124) and CCI more than or equal to 3 (β= 0.088) to be associated with longer hospital LOS (p < 0.001). Operative times, PACU LOS, and procedure times (operative time plus PACU LOS) were not associated with longer hospital LOS (p > 0.05). These data identify associative factors for PACU LOS, as well as the influence of time spent in the PACU on overall hospital LOS. Interestingly, this analysis revealed that patients of arthroplasty fellowship-trained and higher-volume surgeons had longer PACU LOS; however, this could be explained by the observation that these particular surgeons tend to perform more complex deformity cases. Also of importance, increased PACU LOS, meaning the patient spent more time in a high-monitored setting immediately after surgery, did not necessarily confer a longer overall hospital LOS. Based on these data, it may be more beneficial to identify alternate sources than time spent in the operating room or PACU to potentially help reduce overall hospital LOS. LEVEL OF EVIDENCE:  II, prospective cohort.

Why malnutrition in orthopaedic elective patient is still an issue? A recent review of the literature

BACKGROUND

Malnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA). The progressive increase in the ageing of world population and in the numbers of TJA, widens the demand for a faster post-operative recovery and function. The aim of this study was to review the literature regarding: post-operative transfusion, infections, wound complications, length of hospital stay (LOS), rate of admission in intensive care unit (ICU), and total patient charges, in malnourished patient undergoing TJA.

METHODS

The search reviewed all fields of the available peer-reviewed literature, published in the English language during the last seven years 2015-2022. We started from a total of 745 studies and finally we included in the review 16 articles.

RESULTS

In 10 studies, an increased surgical site infection was shown, being by far the most common complication, in 8 studies, malnutrition was associate with the increase of the average length of stay (LOS), and in 5 studies, the major founding was the increase in costs. An increase of the morbidity was found in 3 studies, instead a larger number of transfusions was highlighted in 2 studies. Lastly, one study showed a major unplanned ICU admission rate.

CONCLUSIONS

Although the literature trend indicates that the nutritional status of TJA candidate patients is a parameter that influences the surgical outcome, in particular surgical site infections, length of stay, and costs, there are, to the authors' knowledge, no studies aimed at identifying validated and recognized protocols for the correction of malnutrition.

Rural-Urban Differences in Hospital and Patient-Reported Outcomes Following Total Hip Arthroplasty

Background

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care.

Methods

A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural.

Results

Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P = .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P = .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P = .05), Hip Disability and Osteoarthritis Outcome Score interval (P = .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference.

Conclusions

There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

Length of stay and inpatient charges of total knee arthroplasty in China: analysis of a national database

BACKGROUND

There are limited data on the resource utilization of total knee arthroplasty (TKA) in China. This study aimed to examine the length of stay (LOS) and inpatient charges of TKA in China, and to investigate their determinants.

METHODS

We included patients undergoing primary TKA in the Hospital Quality Monitoring System in China between 2013 and 2019. LOS and inpatient charges were obtained, and their associated factors were further assessed using multivariable linear regression.

RESULTS

A total of 184,363 TKAs were included. The LOS decreased from 10.8 days in 2013 to 9.3 days in 2019. The admission-to-surgery interval decreased from 4.6 to 4.2 days. The mean inpatient charges were 61,208.3 Chinese Yuan. Inpatient charges reached a peak in 2016, after which a gradual decrease was observed. Implant and material charges accounted for a dominating percentage, but they exhibited a downward trend, whereas labor-related charges gradually increased. Single marital status, non-osteoarthritis indication, and comorbidity were associated with longer LOS and higher inpatient charges. Female sex and younger age were associated with higher inpatient charges. There were apparent varieties of LOS and inpatient charges among provincial or non-provincial hospitals, hospitals with various TKA volume, or in different geographic regions.

CONCLUSIONS

The LOS following TKA in China appeared to be long, but it was shortened during the time period of 2013 to 2019. The inpatient charges dominated by implant and material charges exhibited a downward trend. However, there were apparent sociodemographic and hospital-related discrepancies of resource utilization. The observed statistics can lead to more efficient resource utilization of TKA in China.

Effect of Instrumented Spine Surgery on Length of Stay

INTRODUCTION

Total joint arthroplasty studies have identified that surgeries that take place later in the week have a longer length of stay compared with those earlier in the week. This has not been demonstrated in studies focused on anterior cervical diskectomy and fusions or minimally invasive lumbar laminectomies. All-inclusive instrumented spine surgeries, however, have not been analyzed. The purpose of this study was to determine whether day of surgery affects length of stay and whether there are predictive patient characteristics that affect length of stay in instrumented spine surgery.

METHODS

All instrumented spine surgeries in 2019 at a single academic tertiary center were retrospectively reviewed. Patients were categorized for surgical day and discharge disposition to home or a rehabilitation facility. Differences by patient characteristics in length of stay and discharge disposition were compared using Kruskal-Wallis and chi square tests along with multiple comparisons.

RESULTS

Seven hundred six patients were included in the analysis. Excluding Saturday, there were no differences in length of stay based on the day of surgery. Age older than 75 years, female, American Society of Anesthesiology (ASA) classification of 3 or 4, and an increased Charlson Comorbidity Index were all associated with a notable increase in length of stay. While most of the patients were discharged home, discharge to a rehabilitation facility stayed, on average, 4.7 days longer (6.8 days compared with 2.1 days, on average) and were associated with an age older than 66 years old, an ASA classification of 3 or 4, and a Charlson Comorbidity Index of 1 to 3.

CONCLUSIONS

Day of surgery does not affect length of stay in instrumented spine surgeries. Discharge to a rehabilitation facility, however, did increase the length of stay as did age older than 75 years, higher ASA classification, and increased Charlson Comorbidity Index classification.

Establishment and evaluation of a predictive model for length of hospital stay after total knee arthroplasty: A single-center retrospective study in China

Background

Total knee arthroplasty (TKA) is the ultimate option for end-stage osteoarthritis, and the demand of this procedure are increasing every year. The length of hospital stay (LOS) greatly affects the overall cost of joint arthroplasty. The purpose of this study was to develop and validate a predictive model using perioperative data to estimate the risk of prolonged LOS in patients undergoing TKA.

Methods

Data for 694 patients after TKA collected retrospectively in our department were analyzed by logistic regression models. Multi-variable logistic regression modeling with forward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated.

Results

Eight independent predictors were identified: non-medical insurance payment, Charlson Comorbidity Index (CCI) ≥ 3, body mass index (BMI) &gt; 25.2, surgery on Monday, age &gt; 67.5, postoperative complications, blood transfusion, and operation time &gt; 120.5 min had a higher probability of hospitalization for ≥6 days. The model had good discrimination [area under the curve (AUC), 0.802 95% CI, 0.754–0.850]] and good calibration (p = 0.929). A decision curve analysis proved that the nomogram was clinically effective.

Conclusion

This study identified risk factors for prolonged hospital stay in patients after TKA. It is important to recognize all the factors that affect hospital LOS to try to maximize the use of medical resources, optimize hospital LOS and ultimately optimize the care of our patients.

Decreased patient comorbidities and post-operative complications in technology-assisted compared to conventional total knee arthroplasty

PURPOSE

The use of computer-assisted and robotic surgery was developed to improve component position and outcomes of total knee arthroplasty (TKA). The goal of this study is to identify differences in patient demographics, comorbidities, and complications between technology-assisted and conventional TKA.

METHODS

A Nationwide Inpatient Sample database was used to identify patients who underwent technology-assisted and conventional TKA from 2016 to 2018. Analysed variables include demographics, length of stay (LOS), payer-status, geographic region, comorbidities, complications, and mortality. Univariate and multivariate analyses were performed to identify differences between both groups.

RESULTS

The analysis includes 2,208,434 TKA patients, of which 2,054,879 (93.05%) were conventional and 153,555 (6.95%) were technology assisted. Patients undergoing technology-assisted TKA were more likely to be older than 65 years, had higher median income quartile, and had surgery in urban teaching hospitals. Patients were less likely to undergo technology-assisted TKA if they were female gender, had Medicare payer status, were black race, were obese, were living in rural location, or had higher Charlson comorbidity score and baseline comorbidities. Technology-assisted TKA patients had shorter LOS, and fewer pulmonary and infection complications.

CONCLUSION

Patients undergoing technology-assisted TKA are being carefully selected with less baseline comorbidities, improved health, and living in urban areas. Subsequently, those carefully selected patients are discharged home, have a shorted hospital LOS, and have fewer complications compared to conventional TKA. Rural patients, black race and female gender are less likely to undergo technology-assisted TKA, further emphasizing the healthcare disparity for that segment of the population.

LEVEL OF EVIDENCE

Therapeutic level III.

Can a community hospital successfully transition to outpatient total knee arthroplasty in unselected patients?

BACKGROUND

The removal of total knee arthroplasty (TKA) from the Inpatient-Only list in 2018 created pressure on community hospitals to develop rapid discharge protocols (RAP) to increase outpatient discharge. The purpose of this study, therefore, was to compare the efficacy, safety and barriers in achieving outpatient discharge between the standard discharge protocol and newly developed RAP in unselected, unilateral TKA patients.

METHODS

This retrospective chart review included 288 standard protocol patients and the first 289 RAP patients following unilateral TKA in a community hospital. The RAP focused on patient discharge expectations and post-operative patient management, with no change in post-operative nausea or pain management. Non-parametric tests were performed to compare demographics, perioperative variables and 90-readmission/complication rates between standard and RAP groups, as well as between inpatient and outpatient discharged RAP patients. Multivariate, stepwise logistic regression was performed to evaluate patient demographics and discharge status, presented as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Demographics were similar between groups, however, outpatient discharge significantly increased from 22.2% to 85.8% for standard discharge and RAP, respectively (p < 0.001), with no significant difference in post-operative complications. For RAP patients, age (OR:1.062, CI:1.014-1.111; p = 0.011) and female gender (OR:2.224, CI:1.042-4.832; p = 0.039) increased the risk of inpatient and 85.1% of RAP outpatients were discharged home.

CONCLUSIONS

While RAP was successful, 15% of patients required inpatient care and 15% of patients achieving outpatient discharged were not discharged to their home environment, emphasizing the difficulties of achieving true outpatient status in 100% of patients from a community hospital.

Clinical Frailty Scale is a better predictor for adverse post-operative complications and functional outcomes than Modified Frailty Index and Charlson Comorbidity Index after total knee arthroplasty

PURPOSE

Studies have demonstrated correlations between frailty and comorbidity scores with adverse outcomes in total knee replacement (TKR). However, there is a lack of consensus on the most suitable pre-operative assessment tool. This study aims to compare Clinical Frailty Scale (CFS), Modified Frailty Index (MFI), and Charlson Comorbidity Index (CCI) in predicting adverse post-operative complications and functional outcomes following a unilateral TKR.

METHODS

In total, 811 unilateral TKR patients from a tertiary hospital were identified. Pre-operative variables were age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) class, CFS, MFI, and CCI. Binary logistic regression analysis was performed to ascertain odd ratios of pre-operative variables on adverse post-operative complications (length of stay < LOS >, complications, ICU/HD admission, discharge location, 30-day readmission, 2-year reoperation). Multiple linear regression analyses were used to estimate the standardized effects of pre-operative variables on the Knee Society Functional Score (KSFS), Knee Society Knee Score (KSKS), Oxford Knee Score (OKS), and 36-Item Short Form Survey (SF-36).

RESULTS

CFS is a strong predictor for LOS (OR 1.876, p < 0.001), complications (OR 1.83-4.97, p < 0.05), discharge location (OR 1.84, p < 0.001), and 2-year reoperation rate (OR 1.98, p < .001). ASA and MFI were predictors for ICU/HD admission (OR:4.04, p = 0.002; OR 1.58, p = 0.022, respectively). None of the scores was predictive for 30-day readmission. A higher CFS was associated with a worse outcome for 6-month KSS, 2-year KSS, 6-month OKS, 2-year OKS, and 6-month SF-36.

CONCLUSION

CFS is a superior predictor for post-operative complications and functional outcomes than MFI and CCI in unilateral TKR patients. This suggests the importance of assessing pre-operative functional status when planning for TKR.

LEVEL OF EVIDENCE

Diagnostic, II.

Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

BACKGROUND

To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity.

QUESTIONS/PURPOSES

We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?

METHODS

A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively.

RESULTS

Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles.

CONCLUSION

These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

OBJECTIVE

To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).

DESIGN

Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.

SETTING

20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.

PARTICIPANTS

32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).

INTERVENTION

The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.

MAIN OUTCOME MEASURES

The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.

RESULTS

16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).

CONCLUSION

The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.

TRIAL REGISTRATION NUMBER

NCT04055103.

Single-level Lumbar Fusion Versus Total Joint Arthroplasty: A Comparison of 1-year Outcomes

INTRODUCTION

Primary hip and knee arthroplasty represent two of the most successful orthopaedic surgical interventions in the past century. Similarly, lumbar fusion (LF) remains a valuable, evidence-based option to relieve pain and disability related to spinal degenerative conditions. This study evaluates the relative improvements in 1-year health-related quality of life (HRQOL) measures among patients undergoing primary single-level LF, primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA).

METHODS

Patients older than 18 years who underwent primary single-level posterior LF (posterolateral decompression and fusion with or without transforaminal lumbar interbody fusion, involving any single lumbar level), TKA, and THA at a single academic institution were retrospectively identified. Patient demographics and surgical characteristics were collected. HRQOL measures were collected preoperatively and at 1-year postoperative time point including Short-Form 12 Physical Component Score (PCS) and Mental Component Score (MCS) along with subspecialty-specific outcomes.

RESULTS

A total of 2,563 patients were included (346 LF, 1,035 TKA, and 1,182 THA). Change in MCS-12 and PCS-12 after LF did not vary markedly by preoperative diagnosis. LF patients had a significantly lower preoperative MCS-12 (LF: 50.8, TKA: 53.9, THA: 52.9, P < 0.001), postoperative MCS-12 (LF: 52.5, TKA: 54.8, THA: 54.5, P < 0.001), postoperative PCS-12 (LF: 40.1, TKA: 44.0, THA: 43.9, P < 0.001), ΔPCS-12 (LF: 7.9, TKA: 10.8, THA: 11.9, P < 0.001), and PCS-12 recovery ratio (LF: 10.7%, TKA: 15.1%, THA 16.6%, P < 0.001) compared with TKA and THA patients. In regression analysis, both TKA and LF were found to be independently associated with a smaller ΔPCS-12 improvement (TKA: β = -1.36, P = 0.009; LF: β = -4.74, P < 0.001) compared with THA. TKA (β = -1.42, P = 0.003) was also independently associated with a smaller ΔMCS-12 improvement compared with THA.

CONCLUSIONS

Patients undergoing single-level LF, TKA, and THA demonstrate notable improvements in HRQOL outcomes at 1 year postoperatively compared with preoperative baseline scores. The greatest improvements were found among THA patients, followed subsequently by TKA and LF patients. Both LF and TKA were independently associated with markedly less improvement in physical disability at 1 year postoperatively compared with THA.

STUDY DESIGN

Retrospective Cohort Study.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

Predicting Length of Stay using machine learning for total joint replacements performed at a rural community hospital

Background

Predicting patient’s Length of Stay (LOS) before total joint replacement (TJR) surgery is vital for hospitals to optimally manage costs and resources. Many hospitals including in rural areas use publicly available models such as National Surgical Quality Improvement Program (NSQIP) calculator which, unfortunately, performs suboptimally when predicting LOS for TJR procedures.

Objective

The objective of this research was to develop a Machine Learning (ML) model to predict LOS for TJR procedures performed at a Perioperative Surgical Home implemented rural community hospital for better accuracy and interpretation than the NSQIP calculator.

Methods

A total of 158 TJR patients were collected and analyzed from a rural community hospital located in Montana. A random forest (RF) model was used to predict patient’s LOS. For interpretation, permuted feature importance and partial dependence plot methods were used to identify the important variables and their relationship with the LOS.

Results

The root mean square error for the RF model (0.7) was lower than the NSQIP calculator (1.21). The five most important variables for predicting LOS were BMI, Duke Activity Status-Index, diabetes, patient’s household income, and patient’s age.

Conclusion

This pilot study is the first of its kind to develop an ML model to predict LOS for TJR procedures that were performed at a small-scale rural community hospital. This pilot study contributes an approach for rural hospitals, making them more independent by developing their own predictions instead of relying on public models.

Exploring patient acceptability of a short-stay care pathway in hospital post arthroplasty: A theory-informed qualitative study

INTRODUCTION

Arthroplasty is an effective, yet costly, surgical procedure for end-stage osteoarthritis. Shorter stays in hospital are being piloted in Australia. In some countries, short stay is established practice, associated with improving perioperative care and enhanced recovery after surgery practices. Exploring the acceptability to patients of a short stay care pathway in hospital postarthroplasty is important for informing health policy, adoption and potential scalability of this model of care.

METHODS

Consecutive patients at one site, at least 3 months post total joint arthroplasty, were invited to participate in theory-informed semi-structured qualitative interviews. The Theoretical Framework of Acceptability (TFA) informed development of the interview guide. Interview data were analysed using the Framework Method.

RESULTS

Eighteen patients were invited. Fifteen consented to be contacted and were interviewed. Short-stay post arthroplasty was highly acceptable to patients who had the supports necessary to recover safely at home. Key findings were as follows: flexibility of short-stay care pathway was essential and valued; prior beliefs and expectations informed acceptability; and the absence of out-of-pocket expenses had an incentivizing effect, but was not the primary reason for patients choosing this care pathway. Further themes analysed within the TFA constructs highlighted nuances of acceptability relating to this model of care.

CONCLUSIONS

A short stay in hospital post arthroplasty appeared to be acceptable to patients who had experienced this care pathway. Our thematic findings identified aspects of the short-stay care pathway that enhanced acceptability and some aspects that limited acceptability. These findings can inform refinement of the short-stay care pathway.

PATIENT OR PUBLIC CONTRIBUTION

Patients/people with lived experience were not involved in the study design or conduct of this preliminary work; as this short-stay model of care was recently introduced, only a small group of patients was eligible to participate in this study. This study is the first step towards understanding the experiences of patients about a short-stay model of care post arthroplasty. The findings will help inform future patient and public involvement in expanding the programme.

Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study

PURPOSE

Studies comparing clinical outcomes between manual (mTKA) and robotic-assisted TKA (raTKA) are limited. This prospective comparative cohort study aimed to compare early postoperative outcomes, satisfaction, and patient-reported outcome measures (PROMS) between patients undergoing mTKA and ROSA raTKA (Zimmer Biomet, Warsaw, IN) performed by one surgeon.

METHODS

Thirty ROSA raTKAs and 30 mTKAs performed by one surgeon during 2020-2021 were prospectively evaluated. Groups were matched for age, sex, and body mass index. All procedures were primary unilateral TKAs using the same posterior-stabilized prosthesis (Nexgen Legacy, Zimmer Biomet, Warsaw, IN). Length of hospital stay (LOS) and blood transfusion rate were recorded. Complications, visual analogue scale score (VAS), and Oxford Knee Score (OKS) were assessed preoperatively and for six postoperative months. The Forgotten Joint Score (FJS) and patient satisfaction were evaluated 6 months postoperatively.

RESULTS

No complications and similar blood transfusion rate were recorded between groups (p = 0.228). The LOS was non-significantly shorter in raTKA than in the mTKA group (p = 0.120). Mean preoperative and third-month OKS and VAS scores were comparable between groups. However, the mean 6-month OKS (p = 0.006) and VAS score (p = 0.025) were significantly better for the raTKA group. The 6-month FJS was significantly greater for raTKA than the mTKA group (p < 0.001). One patient was unhappy in raTKA, and three in the mTKA group (p = 0.301). Significantly more raTKA patients answered that they would undergo surgery again (p = 0.038).

CONCLUSION

raTKA was associated with the same complication risk, less pain level, better patient satisfaction, and PROMs on 6-month follow-up than the mTKA group.

Differences in hospital length of stay and total hospital charge by income level in patients hospitalized for hip fractures

This study examines the difference in length of stay and total hospital charge by income quartile in hip fracture patients. The length of stay increased in lower income groups, while total charge demonstrated a U-shaped relationship, with the highest charges in the highest and lowest income quartiles.

INTRODUCTION

Socioeconomic factors have an impact on outcomes in hip fracture patients. This study aims to determine if there is a difference in hospital length of stay (LOS) and total hospital charge between income quartiles in hospitalized hip fracture patients.

METHODS

National Inpatient Sample (NIS) data from 2016 to 2018 was used to determine differences in LOS, total charge, and other demographic/clinical outcomes by income quartile in patients hospitalized for hip fracture. Multivariate regressions were performed for both LOS and total hospital charge to determine variable impact and significance.

RESULTS

There were 860,045 hip fracture patients were included this study. With 222,625 in the lowest income quartile, 234,215 in the second, 215,270 in the third, and 190,395 in the highest income quartile. LOS decreased with increase in income quartile. Total charge was highest in the highest quartile, while it was lowest in the middle two-quartiles. Comorbidities with the largest magnitude of effect on both LOS and total charge were lung disease, kidney disease, and heart disease. Time to surgery post-admission also had a large effect on both outcomes of interest.

CONCLUSION

The results demonstrate that income quartile has an effect on both hospital LOS and total charge. This may be the result of differences in demographics and other clinical variables between quartiles and increased comorbidities in lower income levels. The overall summation of these socioeconomic, demographic, and medical factors affecting patients in lower income levels may result in worse outcomes following hip fracture.

Black and Hispanic Patients Do Not Stay Longer After Primary Total Knee Arthroplasty: Results From an Urban Center Serving a Predominantly Minority Cohort

INTRODUCTION

Previous reports identified minority race/ethnicity to be an independent risk factor for prolonged length of stay (LOS); however, these cohorts consisted of predominantly White patients. This study sought to evaluate minority status as an independent risk factor for prolonged LOS after primary total knee arthroplasty (TKA) in a predominantly Hispanic and Black cohort.

METHODS

This was a retrospective study using an institutional database of patients who underwent primary TKA between the years 2016 and 2019. Demographic and socioeconomic data, smoking, body mass index (BMI), medical comorbidities, discharge disposition, and 30-day readmission rates were collected. Patients were first categorized into racial/ethnic groups (Hispanic, Black, or White). An univariate analysis was performed comparing patient characteristics between racial/ethnic groups using the Wilcoxon rank sum, chi-squared, and Fisher exact tests. We then categorized patients into two groups-normal LOS (discharged on postoperative day 1 to 2) and prolonged LOS (discharged after postoperative day 2). An univariate analysis was again performed comparing patient characteristics between LOS groups using Wilcoxon rank sum, chi-squared, and Fisher exact tests. After identifying risk factors markedly associated with LOS, a multivariate logistic regression analysis was performed to identify independent risk factors for prolonged LOS.

RESULTS

A total of 3,093 patients were included-47.9% Hispanic and 38.3% Black. Mean LOS was 2.9 ± 1.6 days. An univariate analysis found race/ethnicity, age, low socioeconomic status (SES), discharge disposition, insurance type, weekday of surgery, BMI >40, smoking, increased American Society of Anesthesiologists (ASA)/Charlson Comorbidity Index (CCI) and several medical comorbidities to be associated with prolonged LOS (P < 0.05). A multivariate logistic regression analysis found Black and Hispanic patients were less likely to have prolonged LOS after adjusting for associated risk factors. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, and increased ASA and CCI were identified as independent risk factors for prolonged LOS (P < 0.05). The overall 30-day readmission rate was 3.6%, with no notable difference between racial/ethnic and LOS groups (P = 0.98 and P = 0.78).

CONCLUSION

In contrast to previous reports, our study found that after adjusting for associated risk factors, minority patients do not have prolonged LOS after primary TKA in an urban, socioeconomically disadvantaged, predominantly minority patient cohort. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, increased CCI, and ASA were all found to be independent risk factors for prolonged LOS. These findings highlight the need to further investigate the role of race/ethnicity on LOS after primary TKA using large-scale, randomized controlled trials with equally represented patient cohorts.

Tempering Expectations for Outpatient Total Knee Arthroplasty for Patients Over 70

BACKGROUND

Total knee arthroplasty (TKA) is now considered an outpatient procedure, yet advanced age impacts patients' ability to achieve outpatient discharge. Therefore, the purpose of this study is to determine the rate of successful outpatient discharge for TKA patients above 70 years of age and identify potential barriers to success.

METHODS

This retrospective review included 352 unilateral TKA patients. The rapid discharge protocol was followed for all patients with the intention of discharge within a 24-hour period. Successful outpatient discharge was classified as ≤24-hour stay and failure was any stay exceeding a 24-hour period in the hospital. Univariate logistic regressions were performed to determine the influence of independent variables on discharge status for all patients and only patients >70 years old.

RESULTS

Overall, 46 patients (13%) failed to achieve outpatient discharge, with 35 (76%) patients being ≥70 years old. For patients ≥70, age was not a predictive variable for failure to achieve outpatient discharge (P = .484). However, being female (odds ratio 3.273, 95% confidence interval 1.286-8.325, P = .013) and the use of an assistive walking device (odds ratio 3.031, 95% confidence interval 1.387-6.625, P = .005) remained independent contributors to prolonged hospital stay.

CONCLUSION

With patients ≥70 years old more likely to require >24-hour stays, age should be an evaluated metric for justifying higher levels of reimbursement. Although TKA is now considered an outpatient procedure, greater consideration should be given to patients ≥70 years old for higher levels of reimbursement as outpatient discharge is less likely to be successful.

Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients

INTRODUCTION

Studies investigating complications between octogenarians and non-octogenarians undergoing primary total knee arthroplasty (TKA) are limited. Therefore, we investigated whether octogenarians are at greater odds of: (1) in-hospital lengths of stay (LOS) (2) readmission rates, (3) medical complications, and (4) hardware complications compared to non-octogenarians following TKA.

METHODS

A retrospective query of the PearlDiver database isolated 1,775,460 patients who underwent primary TKA from 2005 to 2014. Patients aged 80 and above represented the study cohort (n = 295,908) and patients 65 to 79 represented the control cohort (n = 1,479,552). Study group patients were matched to controls in a 1:5 ratio according to gender and medical comorbidities. Pearson's Chi Square and logistic regression were used to analyze the primary outcomes of the study which included 90-day medical complications, 90-day readmission rates, 2-year implant-related complications, and in-hospital LOS. A p-value less than 0.001 was statistically significant.

RESULTS

Octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates (10.59 vs. 9.35%; OR: 1.15, p < 0.0001) and significantly longer in-hospital LOS (3.69 days ± 1.95 vs. 3.23 days ± 1.83, p < 0.0001) compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication (1.26 vs. 1.26%; OR: 0.99, p = 0.99) and lower incidence and odds (1.67 vs. 1.93%; OR: 0.86, p < 0.001) of implant-related complications compared to controls.

CONCLUSION

Octogenarians undergoing primary TKA have similar odds of medical related complications and lower odds of implant-related complications compared to non-octogenarian patients, whereas readmission rates and in-hospital LOS are greater.

Patient-reported outcomes of a short hospital stay after total knee replacement in a regional public hospital: a prospective cohort treated 2018-2019

BACKGROUND

Patient-reported outcomes and satisfaction following short length of stay (LoS) after total knee arthroplasty (TKA) in the Australian regional context remain unexplored. This study reports complications, outcomes and satisfaction of patients discharged from an enhanced recovery protocol (ERP), 6 weeks after TKA in a regional hospital.

METHODS

Prospective recruitment occurred between 2018 and 2019. Demographics, intraoperative data, complications and emergency department (ED) presentations were retrieved from hospital records. Complications were graded for severity using a published scale. Knee range of motion (ROM), timed up-and-go (TUG), 6-min walk test (6MWT) and Oxford Knee Scores (OKS) were assessed preoperatively and 6 weeks postoperatively. Patient satisfaction was assessed via questionnaire at the postoperative follow-up.

RESULTS

One hundred patients/117 primary TKAs were prospectively included. Median LoS was 2 days (interquartile range 1-3 days) with 74.4% and 88.4% of patients satisfied with their knee and LoS, at 6 weeks respectively. Twenty-seven patients presented to the ED a total of 37 times with complication severity of Grade III or less, and 10 patients were readmitted. Significant improvements in objective and subjective outcomes were observed, however only change in median OKS exceeded the minimal clinically important difference (MCID) threshold.

CONCLUSION

An enhanced recovery protocol after TKA in a regional hospital can achieve a median LoS of 2 days without compromising patient-reported outcomes and objective functional measures, whilst maintaining a high level of patient satisfaction with both the surgery and LoS. Further work is required to better optimize management of largely low-grade complications in this patient population.

A nomogram to predict the risk of prolonged length of stay following primary total hip arthroplasty with an enhanced recovery after surgery program

BACKGROUND

The aim of this study was to identify the risk factors associated with prolonged length of stay (LOS) in patients undergoing primary total hip arthroplasty (THA) managed with an enhanced recovery after surgery (ERAS) program and develop a prediction model for improving the perioperative management of THA.

METHODS

In this single-center retrospective study, patients who underwent primary THA in accordance with ERAS from May 2018 to December 2019 were enrolled in this study. The primary outcome was prolonged LOS (> 48 h) beyond the first postoperative day. We collected the clinical patient's clinical characteristics, surgery-related parameters, and laboratory tests. A logistic regression analysis explored the independent risk factors for prolonged LOS. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model to predict the risk of prolonged LOS following primary THA with an ERAS program. Evaluation indicators of the prediction model, including the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis, were reported to assess the performance of the prediction model. The bootstrap method was conducted to validate the performance of the designed nomogram.

RESULTS

A total of 392 patients were included in the study, of whom 189 (48.21%) had prolonged LOS. The logistics regression analysis demonstrated that age, sex, hip deformities, intraoperative blood loss, operation time, postoperative Day 1 (POD) hemoglobin (Hb), POD albumin (ALB), and POD interleukin-6 (IL-6) were independent risk factors for prolonged LOS. The C-index was 0.863 (95% CI 0.808 to 0.918) and 0.845 in the bootstrapping validation, respectively. According to the results of the calibration, ROC curve, and decision curve analyses, we found that the nomogram showed satisfactory performance for prolonged LOS in this study.

CONCLUSIONS

We explored the risk factors for prolonged LOS following primary THA with an ERAS program and developed a prediction model. The designed nomogram was expected to be a precise and personalized tool for predicting the risk and prognosis for prolonged LOS following primary THA with an ERAS program.

Risk factors of postoperative complications following total knee arthroplasty in Korea: A nationwide retrospective cohort study

BACKGROUND

The number of patients undergoing total knee arthroplasty (TKA) is gradually increasing and there is also increase in postoperative complications. The patient's demographic, socio-economic factors, hospital and clinical factors are all factors that can influence postoperative complications. The purpose of this study was to determine the risk factors associated with complications following TKA in a large national cohort.

METHODS

Among patients diagnosed with primary knee arthrosis, a total of 560,954 patients older than 50 years who underwent TKA from January 1, 2005 to December 31, 2018 were included in the study. The risk of postoperative complications (surgical site infection, sepsis, cardiovascular complications, respiratory complications, pulmonary embolism, stroke, acute renal failure, periprosthetic joint infection, and periprosthetic fracture) were assessed with eight independent variables: gender, age, place of residence, household income, hospital bed size, procedure type (unilateral or bilateral, primary or revision TKA), length of stay (LOS), use of transfusion. Multivariable Cox Proportional Hazard model analysis was used. The significant predictors for complications (P < .05) were as follows.

RESULTS

Surgical site infection: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Sepsis: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Cardiovascular complications: male, age, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Respiratory complications: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Pulmonary embolism: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Stroke: male, age, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Acute renal failure: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic joint infection: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic fracture: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion.

CONCLUSION

In summary, male, procedure type (bilateral, revision), LOS (≥35 days), and use of transfusion were shown to be risk factors of postoperative complications following TKA.

Ethnic Disparities and Incidence of Postoperative Complications in Obese Patients Undergoing Total Knee Arthroplasty: Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Set

INTRODUCTION

Total knee arthroplasty (TKA) is common but complex operation. A paucity of literature exists on differences between Hispanics and non-Hispanics with TKA. Our study aims to investigate the association between Hispanic ethnicity and complications in obese patients undergoing TKA.

METHODS

This is a retrospective cohort study using the National Surgical Quality Improvement Program database for patients with body mass index ≥30 kg/m2 who underwent TKA. Exposure in this study was ethnicity (Hispanic versus non-Hispanic), and the primary outcome was postoperative complications. Associations between ethnicity and baseline characteristics and between covariates and the outcome were assessed via bivariate analysis. Multiple logistic regression was done to determine associations between Hispanic ethnicity and complications while controlling for confounders.

RESULTS

Thirty five thousand twenty-seven patients were included in our study, of which 6.3% were Hispanic. Among obese adults, Hispanics had a 1.24 (95% CI 1.11 to 1.39) times greater odds of having a postoperative complication after TKA than non-Hispanics. This increased to 1.36 (95% CI 1.20 to 1.54) after adjusting for confounders. Hispanics were notably more likely to receive transfusion (2.62% vs. 1.59%, P < 0.001) and have prolonged length of stay (13.29% vs. 11.12%, P = 0.002) but were less likely to have wound disruption (0.05% vs. 0.27%, P = 0.042).

CONCLUSION

In a national database, Hispanic ethnicity was associated with greater odds of postoperative complication in obese patients undergoing TKA compared with non-Hispanics. Future studies focusing on a wide range metrics of social determinants of health are needed to further investigate barriers and intervention to eliminate racial/ethnic disparities in surgical patients.

Early postoperative straight leg raise is associated with shorter length of stay after unilateral total knee arthroplasty

PURPOSE

Shorter length of stay (LOS) after total knee arthroplasty (TKA) is cost-effective. Straight leg raise (SLR) is a common exercise prescribed after TKA, but the significance of early postoperative SLR is unknown. The primary aim of this study is to evaluate the association between early postoperative SLR and LOS. Secondary aims are to explore associations among early postoperative SLR, time to ambulation, and time to stairs climbing and identify factors related to postoperative SLR.

METHODS

888 TKAs (888 knees, 865 patients) performed at a tertiary hospital in 2016 were included for this retrospective study. All TKAs were performed with medial parapatellar approach and tourniquet. Time to events (SLR, ambulation, stair climbing), LOS and factors influencing these events were analysed using a multivariate Poisson regression model and logistic regression.

RESULTS

Patients who performed SLR on postoperative day 1 (POD1) had shorter LOS than those who did not (adjusted Mean Ratio (aMR) = 0.846, p < 0.001), with estimated mean LOS being 3.5 days and 4.1 days, respectively. Performing SLR on POD1 was also associated with shorter time to ambulation (aMR = 0.789; p < 0.001) and stair climbing (aMR = 0.811, p < 0.001). Female gender and higher rest pain on POD1 were associated with delayed postoperative SLR.

CONCLUSION

Performing SLR on POD1 after TKA is associated with shorter LOS, time to ambulation, and time to stair climbing. Early postoperative SLR can prognosticate early recovery and discharge. Optimization of preoperative muscle strength and postoperative pain may be important in early recovery after TKA.

Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

BACKGROUND

Although frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.

METHODS

The National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.

RESULTS

We identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.

CONCLUSION

Disparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.

Aseptic Revision Total Knee Can Be Performed as Part of a Short-Stay Arthroplasty Program: An Analysis of the National Surgical Quality Improvement Program Database

Total knee arthroplasty (TKA) is becoming an increasingly common procedure to alleviate knee pain often associated with osteoarthritis. As the number of revision TKAs performed continues to increase, there remains a debate regarding the efficacy of discharging patients earlier than the conventional 3 to 4 days in the postoperative period. A variety of studies have begun to show that interchangably discharge in the primary TKA setting has an economical benefit while causing either a reduction or no difference in patient outcomes. This study aims to determine the effect of rapid discharge at 0- to 2-day postoperative stay compared to the conventional 3- to 4-day postoperative stay on postdischarge complications in patients undergoing revision TKA. A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent aseptic revision TKA between 2005 and 2016 were identified and stratified into groups based on length of stay: 0 to 2 days versus 3 to 4 days. Patients suffering from predischarge complications were excluded to minimize bias. Single-component versus both-component revisions were analyzed. The incidence of adverse events following discharge was evaluated with univariate and logistic multivariate analyses where appropriate. Patients who underwent single-component revisions and were discharged rapidly were less likely to develop minor complications (p = 0.001; odds ratio [OR]: 0.355; 95% confidence interval [CI]: 0.188-0.671) and septic complications (p = 0.016; OR: 0.011; 95% CI: 0-0.430) within the 30-day postoperative period. No differences were observed in discharge cohorts among patients undergoing both-component revisions. We found that rapid discharge following aseptic revision TKA is not associated with increased risks for postoperative complications. Rapid discharge may have benefits for healthy patients undergoing single-component revisions. Careful selection of revision TKA patients for rapid discharge may help to lower the increasing costs of the procedure and improve patient outcomes. Further study is required to refine the selection criteria to identify patients eligible for short stay or outpatient revision TKA.

What Is the Likelihood of Union After Coronal Limb Realignment Using Revision Osteosynthesis and Concurrent TKA in Patients with Advanced Arthritis and Loss of Fixation After Distal Metaphyseal Femur Fractures?

BACKGROUND

Metaphyseal fracture healing in the distal femur requires a stable biomechanical environment. The presence of arthritis-induced coronal-plane knee deformities can cause deviation of the mechanical axis, which results in asymmetric loading and increased bending forces in fractures of the distal femur metaphysis. This predisposes patients to nonunions or loss of fixation. Concurrent TKA during revision osteosynthesis might facilitate fracture healing, owing to its ability to correct coronal alignment, thereby restoring normal loading patterns at the fracture site, but to our knowledge, this has not been studied.

QUESTIONS/PURPOSES

(1) Does TKA with concurrent revision internal fixation achieve fracture union in patients with coronal-plane deformity from knee arthritis and nonunion or loss of fixation in distal metaphyseal femoral fractures? (2) What is the survivorship and what are the short-term functional outcomes after these reconstructions? (3) What complications occur after these reconstructions?

METHODS

Between 2015 and 2018, one surgeon treated 16 patients with a distal metaphyseal femur fracture nonunion and/or loss of fixation using concurrent TKA plus revision internal fixation. Autologous iliac crest bone grafting was performed in five patients with evident gaps at the fracture site. The indications for the procedure included patients older than 55 years of age presenting with a nonunion and/or loss of fixation of a distal metaphyseal femur fracture in the setting of painful Ahlbäck Grade III to V knee arthritis with an associated coronal-plane deformity. All patients meeting these indications were treated with this approach during the study period. Fracture union assessed by radiological bridging of at least three cortices, TKA survival free from revision due to any reason, coronal-plane correction using tibiofemoral angle, and patient mobility status assessed presurgery and at follow-up using the Parker mobility score (scored 0-9 points, with 9 indicating best mobility) were assessed by two surgeons who were not involved in the care of the study patients. Immediate and delayed complications were recorded. Patients were followed for a minimum of 24 months. The median (range) follow-up was 38 months (27 to 52 months).

RESULTS

All fractures united after concurrent TKA plus revision internal fixation. In all, 14 of 16 fractures healed before 5 months, while the remaining two fractures united by 6 months. Survivorship analysis revealed a TKA component survival of 94% (95% CI 63% to 99%) at 52 months. The median (range) preoperative Parker mobility score of 5 points (3 to 8) improved to 7 points (2 to 9) at 12 months postoperatively and was maintained at last follow-up (p = 0.001). Four patients experienced complications; these were (1) prolonged surgical wound drainage resulting in debridement and polyethylene liner exchange, (2) deep knee infection needing a staged revision, (3) popliteal vein thrombosis, and (4) prolonged graft site pain.

CONCLUSION

Concurrent TKA plus revision internal fixation is effective for achieving union in patients with distal metaphyseal femur nonunion and loss of fixation in the setting of coronal-plane deformity induced by knee arthritis. Short-term TKA survival and improvement in patient mobility are excellent, although 4 of 16 patients in this report experienced complications, as one might expect with a procedure of this magnitude. Based on our results, correction of arthritis-induced coronal-plane knee malalignment can be considered part of the surgical strategy when treating such distal metaphyseal femur nonunions. Better preoperative evaluation of the deformity and control-based comparative studies can further validate the utility of this technique.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Total knee arthroplasty in dialysis patients: Is it safe? A systematic review of the literature

Purpose

This systematic review characterizes the safety and efficacy of total knee arthroplasty (TKA) in end stage renal disease (ESRD) patients due to the unique challenges they face.

Results

The cumulative complication rate for 3684 patients on dialysis for ESRD after primary TKA was 25%(N = 925/3702), with incidence rates of 2.5%(N = 92/3702) for periprosthetic joint infection, 3.7%(N = 71/1895) for reoperations, and 2.5%(N = 90/3578) for mortality.

Conclusion

Patients on dialysis for ESRD face significant mortality rates after primary TKA, in addition to other major complications. Careful counseling regarding risks and benefits should be provided prior to TKA in this population.

Factors Affecting Hospital Length of Stay following Total Knee Replacement: A Retrospective Analysis in a Regional Hospital

In an effort to reduce hospital length of stay (LoS) following total knee arthroplasty (TKA), patient management strategies have evolved over time. The aims of this study were threefold: first, to quantify the reduction in LoS for TKA in a regional hospital; second, to identify the patient, surgical and management factors associated with hospital LoS; and lastly, to assess the change in complications incidence and hospital readmission as a function of LoS. A retrospective chart review was conducted on a consecutive series of primary and revision TKAs from January 2012 to March 2018. Factors describing patient demographics, as well as preoperative, intraoperative, surgical, and postoperative management, were extracted from paper and electronic medical records by a team of reviewers. Multivariate linear regression was performed to assess the association between these factors and LoS. In total, 362 procedures were included, which were reduced to 329 admissions once simultaneous bilateral procedures were taken into account. Median LoS reduced significantly (p = 0.001) from 6 to 2 days over the period of review. A stepwise regression analysis identified patient characteristics (age, gender, comorbidities, discharge barriers), perioperative management (anesthesia type), surgical characteristics (approach, alignment method), and postoperative management (mobilization timing, postoperative narcotic use, complication prior to discharge) as factors explaining 58.3% of the variance in LoS. Representation to emergency (6%) and hospital readmission (3%) remained low for the reviewed period. Efforts to reduce hospital LoS following TKA within a regional hospital setting can be achieved over time without significant increases in the rate or severity of complications or representation to acute care and subsequent readmission. The findings establish the role of patient, surgical and management factors in the context of agreed discharge criteria between care providers.

To Predict the Length of Hospital Stay After Total Knee Arthroplasty in an Orthopedic Center in China: The Use of Machine Learning Algorithms

Background and Objectives: Total knee arthroplasty (TKA) is widely performed to improve mobility and quality of life for symptomatic knee osteoarthritis patients. The accurate prediction of patients' length of hospital stay (LOS) can help clinicians for rehabilitation decision-making and bed assignment planning, which thus makes full use of medical resources.

Methods: Clinical characteristics were retrospectively collected from 1,298 patients who received TKA. A total of 36 variables were included to develop predictive models for LOS by multiple machine learning (ML) algorithms. The models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance and decision curve analysis (DCA) for clinical values. A feature selection approach was used to identify optimal predictive factors.

Results: The areas under the ROC curve (AUCs) of the nine models ranged from 0.710 to 0.766. All the ML-based models performed better than models using conventional statistical methods in both ROC curves and decision curves. The random forest classifier (RFC) model with 10 variables introduced was identified as the best predictive model. The feature selection indicated the top five predictors: tourniquet time, distal femoral osteotomy thickness, osteoporosis, tibia component size, and post-operative values of Hb within 24 h.

Conclusions: By analyzing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA, and the RFC model performed the best.

Pressure injuries, obesity and mental health concerns on admission to rehabilitation are associated with increased orthopaedic rehabilitation length of stay

OBJECTIVE

To investigate the association between a set of comprehensive factors across international literature and rehabilitation length of stay.

METHOD

A chart audit of 197 Australian hospital rehabilitation unit orthopaedic inpatients (2016-2018) was conducted. Items significantly associated with length of stay throughout univariate regressions were entered into a subsequent hierarchical multiple regression analysis, where variables were regressed against length of stay in two steps. Items which were relevant prior to admission to the rehabilitation unit, or immediately upon admission, were regressed against length of stay during the first step, while variables which emerged during admission were entered during the second step.

RESULTS

Having pressure injuries during rehabilitation (p < .001), limited compliance in rehabilitation programs (p = .007), mental health concerns on admission to rehabilitation (p = .007), being obese (p < .001), and having significant pain impacting function (p = .03) were all independently significantly associated with an increased length of stay. Higher Functional Independence Measure motor (p < .001) subscale scores on admission to rehabilitation were associated with decreased length of stay. A hierarchical multiple regression analysis found that pressure injuries during rehabilitation (p = .002), being obese (p = .04), having mental health concerns on admission to rehabilitation (p = .03), and Functional Independence Measure subscale scores on admission (p = .04) were significantly associated with length of stay.

CONCLUSION

It is imperative that clinical programs and interventions promoting mental health outcomes, and addressing the distinct needs of obese inpatients, are delivered in the rehabilitation context.

Postoperative Complications Causing Readmission in 30 Days after Total Knee Arthroplasty: A Retrospective Nested Case-Control Study of Risk Factors Based on Propensity Score Matching

We performed this study to identify independent risk factors for life-threatening postoperative complications causing 30-day readmissions after total knee arthroplasty (TKA). Improved understanding of these risks may improve efficiency and safety of treatment. We performed a retrospective, nested case-control study using an open-access database of 2,622 patients who underwent primary TKA at a tertiary academic medical center in Singapore between January 2013 and June 2014. Patients were grouped according to the incidence of complications. Multivariate logistic analysis was performed to identify predictive factors for TKA complications. The incidence of postoperative complications was 1.72%. Compared with cases performed with an operative time < 70 minutes, increased operative time was associated with a higher risk of complications. Case duration > 90 minutes was associated with an increased risk (adjusted odds ratio [aOR] = 4.57, p = 0.001; case duration ≥ 111 minutes, aOR = 4.64, p = 0.04; and case duration between 91 and 110 minutes, aOR = 3.20, p = 0.03). The correlation between operative time and complications was nonlinear. Cerebrovascular accident (CVA) or transient ischemic attack (TIA) was an independent risk factor for increased complication rate (aOR = 11.59, p = 0.02). Operative duration has been identified as an independent risk factor for complications after TKA. As it remains a modifiable factor to which doctors are interested in bringing quality improvement, the risk of postoperative complications will be reduced by minimizing the operative duration.

What Are the Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain Following Primary Total Knee Arthroplasty?

BACKGROUND

Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid).

METHODS

A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated.

RESULTS

A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824).

CONCLUSION

Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups.

LEVEL OF EVIDENCE

III, Retrospective Observational Analysis.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications

BACKGROUND

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS.

METHODS

The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality.

RESULTS

There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts.

CONCLUSIONS

Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Why Do Patients Stay Longer Than Three Nights Following Hip and Knee Arthroplasty?

BACKGROUND

Prolonged length of stay (PLOS) is frequently cited by secondary data studies as an adverse outcome following hip and knee arthroplasty. Although perhaps indisputable that PLOS increases the cost of hospitalization, it is unknown whether it is an appropriate measure of the quality of an arthroplasty procedure.

METHODS

We searched our institution's database for all hip and knee arthroplasty procedures over a 5-year period using MS-DRG (Medicare Severity-Diagnosis Related Group) 469 and 470. Cases with greater than 3 night stays were identified. Charts were manually reviewed by 2 independent reviewers to identify the primary reason for PLOS, and the need for 30-day readmission or reoperation.

RESULTS

Of a total 4347 hip and knee arthroplasty cases, 218 (5.0%) were identified with LOS greater than 3 nights. The majority of prolonged stays were due to exclusively medical reasons (81 cases: 37.2%; 95% confidence interval [CI] 31.0-43.7). The second most common cause was inpatient days prior to the arthroplasty procedure (45 cases: 20.6%; 95% CI 15.8-26.5). Orthopedic reasons for PLOS were significantly less common than medical reasons (36 cases: 16.5%; 95% CI 12.2-22.0, P < .0001), most often due to failure to meet therapy goals. Neither readmission (31 cases: 14.2%) nor reoperation (10 cases: 4.6%) was associated with an underlying reason for PLOS.

CONCLUSION

When evaluating LOS as a measure of quality of an arthroplasty procedure, readers of secondary "big data" studies should be aware that there are significant limitations to its utility. Even after controlling for potential confounders, we found that PLOS does not necessarily reflect an adverse outcome.

Postacute Care Disposition for Total Hip and Total Knee Replacement Surgery for Asian Americans

This study explored differences in postacute disposition for total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a focus on whether Asian Americans (AS) experience joint replacement disparities observed in other racial/ethnic minorities compared with majority white patients. We used data from the Nationwide Inpatient Sample for 2009 through 2012. We looked at disposition to home health care (HHC) and transfer to another facility for postacute care (e.g., skilled nursing facility, rehabilitation facility) for each of the 4 years under study. Findings for AS were mixed. There were differences in discharge to postacute facilities other than HHC for AS compared with whites for THA for 2011 and 2012. For TKA, there were differences in disposition to HHC for Asians compared with whites for 2009 and 2012; for disposition to postacute facilities other than HHC for TKA, there were differences for 2011 and 2012 only. Differences for AS in postacute disposition to facilities other than HHC appear to increase over the 4 years of the study. Further research with additional data is warranted.

Do Patient Point of Entry and Medicaid Status Affect Quality Outcomes Following Total Knee Arthroplasty?

BACKGROUND

The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA.

METHODS

The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers.

RESULTS

There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of "other' ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026).

CONCLUSION

Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS.

LEVEL OF EVIDENCE

III, retrospective observational analysis.

Impact of surgical instrumentation on hospital length of stay and cost of total knee arthroplasty

BACKGROUND

We aimed to analyze the impact of two different types of surgical instrumentation (conventional manual instrumentation (CI) and patient-specific instrumentation (PSI)) on length of stay (LOS) and objectify differences in cost. We hypothesized that there are no differences in the LOS and cost due to the instrumentation system used.

RESEARCH DESIGN AND METHODS

LOS was registered using inpatient admission data provided by the Institutional Management Control Department. We recorded the costs associated with each procedure that could be influenced by the use of one system or another during the in-hospital stay. We conducted a prospectively single-center cohort study of 305 TKAs. Surgery was performed with conventional CI in 122 cases and with PSI in 183 cases.

RESULTS

The mean LOS for the CI group was 4.29 days (SD 1.65) and 4.22 days (SD 1.26), for the PSI group. No significant difference among both instrumentation systems was obtained. When comparing global costs, the mean cost was slightly higher (without a significant difference) for the PSI cases (€3110.24 vs. €2852.7 for the CI cases).

CONCLUSIONS

LOS and overall cost, in hospitals with a low annual TKA surgery volume, are unrelated to conventional or patient-specific instrumentation.

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.

RESULTS

A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.

CONCLUSIONS

Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty

BACKGROUND

Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA.

METHODS

Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours.

RESULTS

A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours.

CONCLUSION

This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

Predictors of extended length of stay after unicompartmental knee arthroplasty

PURPOSE

To identify factors that independently predict extended length of stay after unicompartmental knee arthroplasty (UKA) surgery (defined as length of stay longer than 3 days), and to identify factors predicting early post-operative complications.

METHODS

A retrospective analysis of all patients undergoing UKA from January 2016-January 2019 at our institution was performed. Clinical notes were reviewed to determine the following information: Patient age (years), gender, American Society of Anesthesiologists (ASA) grade, weight (kg), height (meters), body mass index (BMI), co-morbidities, indication for surgery, surgeon, surgical volume, surgical technique (navigated or patient-specific instrumentation), implant manufacturer, estimated blood loss (ml), application of tourniquet during the surgery, application of drain, hospital length of stay (days) and surgical complications.

RESULTS

Multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 4.4 (CI; 1.8-10.8, p = 0.001)] and a history of cardiovascular disease [OR 2.8 (CI; 1.4-5.5), p = 0.004)] were significant independent predictors of prolonged length of stay. Hosmer-Lemeshow goodness of fit of the model showed a p-value of 0.214. Nagelkerke R-Square was 0.2. For complications, multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 5.8 (CI; 1.7-20.7)] and high BMI (BMI >30) [OR 4.3 (CI; 1.1-17.1)] were significant independent predictors of complications. Hosmer-Lemeshow goodness of fit was 0.89 and Nagelkerke R-Square was 0.2. Patients treated with robotics (Navio) techniques had shorter length of stay median 51 h (IQR; 29-96) when compared to other techniques 72 h (IQR; 52-96), p = 0.008.

CONCLUSION

Based on the results of our study, high ASA grade (≥3) appears to be the most important factor excluding eligibility for fast-track UKA. Any number of co-morbidities may increase ASA, but in and of themselves, apart from a history of cardiovascular disease, they should not be seen as contraindications. Appropriate patient selection, technical tools and details during the surgery could facilitate fast track surgery.

Perioperative predictors of prolonged length of hospital stay following total knee arthroplasty: a retrospective study from a single center in China

Background

Decreasing the length of hospital stay is an ideal course of action to appropriately allocate medical resources. The aim of this retrospective study was to identify perioperative factors that may decrease the length of hospital stay (LOS).

Methods

In this study, we collected the data on 1112 patients who underwent primary total knee arthroplasty surgery (TKAs) at our institution from Jan 1, 2011 to Nov 31, 2017. Based on the published literature, 16 potential factors (12 preoperative variables, 1 intraoperative variable, and 3 postoperative variables) were investigated. The patients requiring a hospital stay longer than the mean LOS (8 days) were defined as patients with a prolonged LOS. The factors with a P value less than 0.1 in the univariate analysis were further analysed in a multivariate model. An ordinal regression was used to determine independent risk factors for a prolonged LOS.

Results

The mean LOS was 8.3 days (±4.3), with a range of 2 to 30 days. Sixteen variables were analysed by univariate analysis, and 11 of them had p < 0.1 and were included in the multivariable model. Finally, 9 factors were found to be associated with a prolonged LOS. Among the 9 variables, 2 were surgery-related factors (operative time and intraoperative blood loss), and 3 were patient-related factors (age, ASA classification and neurological comorbidities).

Conclusion

In this study, we found that the clinical protocol, complications, the patient’s age, the ASA classification, neurological comorbidities, the operative time, the ward, intraoperative blood loss and the surgeon were all factors contributing to a prolonged LOS. In clinical practice, these factors provide important information for the surgeon and are useful for identifying patients with a high risk of a prolonged LOS.