Comparison of Outpatient vs Inpatient Total Knee Arthroplasty: An ACS-NSQIP Analysis

Enhancing recovery and reducing readmissions: The impact of remote monitoring on acute postoperative care in outpatient total joint arthroplasty

Introduction

Outpatient total joint arthroplasty (TJA) is gaining popularity in the United States. With a shift towards value-based healthcare and bundled payment models, the importance of safe discharge after TJA is pertinent in reducing readmissions and subsequent cost of care. However, many acute issues or complications may not occur until after discharge which can result in emergency department visits and readmission. Our study aims to characterize the effect of remote monitoring devices on acute postoperative recovery in TJA discharged within 24 h. We hypothesized there would be a decreased readmission rate in the remote home monitoring cohort.

Methods

This prospective cohort compared 50 outpatient TJAs (primary total hip and total knee replacements) defined as discharged within 24 h with a remote home monitoring device to 50 outpatient TJAs who did not receive remote monitoring. Demographics, hospital length of stay, American Society of Anesthesiology scores, and Charlson Comorbidity Index were compared with no significant difference observed between cohorts (p > 0.05). Patients' vital signs were transmitted to a virtual response center for up to 48 h after discharge. An on-call medical team reviewed the transmissions and if prompted, would contact the patient to troubleshoot and triage. Primary outcome was 30-day hospital readmissions rates, while 30-day ED visits and patient satisfaction scores for the remote home monitoring were measured as secondary outcomes.

Results

Within the remote monitoring cohort there was a 20 % incidence (10 patients) of abnormal vitals captured and 2 patients visited the ED, however there were no readmissions attributed to this group. Readmission rates and ED visits in the control non-monitored group were significantly higher at 12 % (p = 0.03), secondary to syncope, uncontrolled postoperative pain, cellulitis, hip dislocations, and postoperative fever. Of the patients who received remote monitoring, 14 % had trouble connecting the device to their smartphone, 44 % felt home monitoring helped in their care while recovering at home, 52 % made them feel safer, and 70 % would recommend this program.

Conclusions

Remote home monitoring with a virtual response team after outpatient TJA is a feasible way to mitigate readmissions in the acute postoperative period and increase patient satisfaction. Efforts to minimize costs should not be implemented at the expense of patients' health outcomes with a goal to find an appropriate balance between both agendas.

Level of evidence

Therapeutic Level III.

The Removal of Total Knee Arthroplasty From the Inpatient-Only List has Improved Patient Optimization

INTRODUCTION

On January 1, 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list, expanding outpatient TKA (oTKA) to include patients with insurance coverage through their programs. These regulatory changes reinforced the need for preoperative optimization to ensure a safe and timely discharge after surgery. This study compared modifiable preoperative optimization metrics in patients who underwent oTKA pre-IPO and post-IPO removal. The authors hypothesized that patients post-IPO removal would demonstrate improvement in the selected categories.

METHODS

Outpatient TKA in a national database was identified and stratified by surgical year (2015 to 2017 versus 2018 to 2020). Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, hematocrit, sodium, smoking, and body mass index. The percentage of patients who did not meet thresholds pre-IPO and post-IPO removal were compared.

RESULTS

In total, 2,074 patients underwent oTKA from 2015 to 2017 compared with 46,480 from 2018 to 2020. Patients undergoing oTKA after IPO removal were significantly older (67.0 versus 64.4 years; P < 0.01). A lower percentage of patients in the post-IPO cohort fell outside the threshold for all modifiable risk factors. Results were significant for preoperative sodium (10.7% versus 8.8%; P < 0.01), body mass index (12.4% versus 11.0% P = 0.05), and smoking history (9.9% versus 6.6%; P < 0.01).

CONCLUSION

Outpatient TKA has increased considerably post-IPO removal. As this regulatory change has allowed older patients with increased comorbidities to undergo oTKA, the need for appropriate preoperative optimization has increased. The current data set demonstrates that surgeons have improved preoperative optimization efforts for select modifiable risk factors.

Successful 24-hour discharge for total knee arthroplasty: importance of timing of surgery and physiotherapy in enhanced recovery after surgery protocol

INTRODUCTION

The current literature is mixed on which patient factors, if any, predict the rate of successful discharge within 24 h of enhanced recovery after surgery (ERAS) total knee arthroplasty (TKA). This study aimed to investigate the influence of timing of surgery and physiotherapy on the rate of successful 24-h discharge.

METHODS

All 342 patients who underwent ERAS day surgery TKA from August 2020 to July 2021 were followed up prospectively. Patient characteristics and postoperative outcomes, such as number of physiotherapy sessions required before clearance for home, time taken after surgery to ambulate >10 m and length of stay (LOS), were recorded. Patients were grouped based on surgical end time (morning/afternoon/ evening) and time of physiotherapy review (morning/afternoon/evening/morning after). Patients successfully passed ERAS day surgery protocol if they were discharged within 24 h.

RESULTS

With regard to the timing of operation, the morning group had the shortest LOS (P = 0.001) and a higher ERAS day surgery pass rate than the afternoon group (P = 0.016). With regard to the timing of physiotherapy, the afternoon group took the shortest time to ambulate >10 m (P < 0.001), had the shortest LOS (P < 0.001) and had a higher ERAS day surgery pass rate as compared to the morning after the operation group (P = 0.005).

CONCLUSION

Patients who ended their operations in the morning and received physiotherapy review in the same afternoon were the most likely to be discharged within 24 h due to early ambulation and adequate time for spinal anaesthesia to wear off.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends

Background

While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon.

Methods

The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts.

Results

Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001).

Conclusion

To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND

In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database.

METHODS

White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities.

RESULTS

A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673).

CONCLUSION

Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

Trends in unicompartmental knee arthroplasty among 138 international experienced arthroplasty knee surgeons

Purpose

Unicompartmental knee arthroplasty (UKA) is an established option for treating isolated unicompartmental knee osteoarthritis (OA), but controversies still exist about patient selection, indications, perioperative management and alignment goals. This survey was designed to understand the current trends of experienced arthroplasty knee surgeons performing UKA.

Methods

An online questionnaire was created with SurveyMonkey® to assess global tendencies in the utilization of UKA. A link to the survey was shared with all ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) members. The questionnaire consisted of free and multiple-choice questions and was divided into four sections: demographic information, the surgical activity of the respondents, indications for surgery and postoperative alignment goals.

Results

A total of 138 ESSKA members from 34 different countries completed the survey. A total of 81 % of the responders performed fewer than 50 UKAs per year; 53 % of UKAs represented less than 20 % of their knee replacements; 71 % used mainly or only fixed-bearing implants; 81 % performed UKA in a shorter time compared to TKA; and 61 % and 72 % were interested in custom-made UKA and robotics, respectively. Thirty-six percent considered a minimum postoperative alignment of 0° for medial UKA, and 32 % considered 10° as the maximum valgus deformity for lateral UKA. Fifty-five percent had no minimum age cut-off, 47 % had no BMI cut-off, and 57 % believed TKA was better than UKA in knees with concomitant high-grade patellofemoral OA. Approximately 50 % of the surgeons desired a coronal alignment that was the same as the predegeneration alignment.

Conclusion

A high level of agreement was reached regarding the following: preference for fixed-bearing UKAs, lower surgical time for UKA compared to TKA, interest in custom-made and robotic UKAs, no age and weight cut-off, TKA preferred in the presence of patellofemoral OA, and a final alignment goal of the predegenerative state both for medial and lateral. There was no agreement regarding length of stay, rehabilitation protocol, preoperative varus and valgus cut-off values, and treatment in cases of absence of anterior cruciate ligament or previous osteotomy.

Safety of Outpatient Total Hip Arthroplasty Performed in Patients 65 Years of Age and Older in an Ambulatory Surgery Center

Studies regarding the safety of same day discharge (SDD) in patients ≥65 years of age undergoing total hip arthroplasty (THA) are lacking. A retrospective review of 69 patients undergoing SDD following primary THA in 2 free-standing ambulatory surgical centers (ASCs) was performed to evaluate for safety and complications. Sixty-six patients met SDD goals, while 1 patient required transport to a hospital for transfusion, and 2 patients underwent overnight observation in the ASC. This study reveals that with appropriate preoperative evaluation, patient selection, and education, THA in a free-standing ASC can be safely performed in patients ≥65 years of age.

Higher Risk of Reoperation after Total Knee Arthroplasty in Young and Elderly Patients

As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40-49 years), middle (50-79 years), and elderly (80-89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays (p < 0.001) but longer operative times (p < 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia (p < 0.001), acute renal failure (p < 0.001), stroke (p < 0.001), cardiac arrest (p < 0.001), and transfusions (p < 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% (p < 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications

Introduction

An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database.

Methods

Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities.

Results

Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA.

Conclusion

Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.

Low readmission and reattendance rate in day-case total knee arthroplasties

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Methods

Day-case TKAs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction.

Results

Since 2016, 301/7350 TKAs (4.1%) in 290 patients at our institution were discharged on the day of surgery. Mean follow-up was 31.4 months (6.2 to 70.0). In all, 28 patients (9.3%) attended the emergency department or other acute care settings within 90 days of surgery, most often with wound concerns or leg swelling; six patients (2.0%) were readmitted. No patients underwent a subsequent revision procedure, and there were no periprosthetic infections. Two patients (0.7%) underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients (1.0%) underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 patients (7.8%) contacted their general practitioner within two weeks postoperatively; two (1.0%) were referred to secondary care. Overall, 115/121 patients (95%) telephoned stated they would have day-case TKA again.

Conclusion

Day-case TKA can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the postoperative period, and high patient satisfaction.

An ACS-NSQIP Analysis of Unicompartmental Knee Arthroplasty Trends from 2013 to 2018

Unicompartmental knee arthroplasty (UKA) volume has increased with advances in implant design, perioperative protocols, and patient selection. This study analyzed national trends of UKA from 2013 to 2018 and the relationship between patient demographics and postoperative outcomes. Data on UKA (CPT 27446) from 2013 to 2018 was collected from the National Surgical Quality Improvement Program (NSQIP). Variables collected included patient demographics, American Society of Anesthesiology classification, functional status, NSQIP morbidity probability, operative time, length of stay, 30-day reoperation, and readmission rates. There was an increase in outpatient UKAs performed (920 in 2013; 11,080 in 2018) (p < 0.0001). Analysis of variance from 2013 to 2018 revealed significant decrease in patient body mass index (BMI) (32.5 in 2013; 31.5 in 2018) (p < 0.01) and NSQIP morbidity probability (0.014 in 2013; 0.011 in 2018) (p < 0.0001). Operative time increased (79.1 minutes in 2013; 84.4 minutes in 2018) (p < 0.01), but length of stay decreased (0.9 days in 2013; 0.5 days in 2018) (p < 0.0001). The number of all-cause and related readmissions decreased significantly (p < 0.045; p < 0.01). Age, male gender, BMI >40 and chronic obstructive pulmonary disease (COPD) were significant predictors for 30-day readmission. BMI >40 was a significant predictor for discharge destination. UKA has seen a rise in incidence from 2013 to 2018 with an increasing number of outpatient UKAs. Operative times and 30-day readmissions have both decreased in this time. BMI > 40 is predictive for discharge destination after UKA, while age, male gender, BMI >40, and COPD are independent risk factors for 30-day readmission.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

IPO policy implementation in 2018.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty

BACKGROUND

As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence.

METHODS

Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression.

RESULTS

The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD.

CONCLUSIONS

The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.

An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis

Background

The coronavirus disease 2019 (COVID-19) pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip and total knee arthroplasty.

Methods

This retrospective study split patients into cohorts: TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following the resumption of elective surgeries (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index, American Society of Anesthesiologists score, and pertinent comorbidities were analyzed, and length of stay, 30-day emergency department (ED) visit rates, readmissions, and reoperations were compared.

Results

A total of 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (interquartile range 63-76), and the post-COVID group had a median age of 68 years (interquartile range 61-75) (P = .024). SDD increased from 0.1% to 28.9% (P < .001), and length of stay decreased from 1.3 days to 0.89 days (P < .001). There was no change in 30-day ED visits, readmissions, or reoperations (P = .817, P = .470, and P = .643, respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P < .001, odds ratio [OR] = 0.94), body mass index (P = .006, OR = 0.95), male sex (P < .001, OR = 1.83), and history of tobacco use (P < .001, OR = 1.87).

Conclusions

At our institution, the COVID-19 pandemic accelerated the utilization of SDD pathways without increasing ED visits, readmissions, or reoperations.

Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations

BACKGROUND

Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations.

METHODS

Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations.

RESULTS

A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations.

CONCLUSION

In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.

Hospital Readmissions After Total Joint Arthroplasty: An Updated Analysis and Implications for Value-Based Care

BACKGROUND

While risk factors have been published for readmissions following primary total joint arthroplasty, little is known about the etiology of those costly adverse events. In this study, we sought to identify the reasons for 30-day readmission following primary total joint arthroplasty in a contemporary national patient sample.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify 367,199 patients who underwent primary total knee (TKA) or hip arthroplasty (THA) between 2011 and 2018. The primary outcomes were the annual rates of 30-day readmissions and the causes of those readmissions.

RESULTS

The 30-day readmission rate trended downward from 4.5% in 2011 to 3.3% in 2018. Medical complications accounted for 52.6% and 38.5% of readmissions following TKA and THA, respectively. Diseases of the circulatory system, abnormal laboratory values, and diseases of the digestive system were the leading causes of medical readmissions. Surgical complications accounted for 37.7% and 50.7% of readmissions following TKA and THA, respectively. Surgical site infections/wound disruption and venous thromboembolism were the leading two causes of surgical readmissions for THA and TKA. Prosthetic complications-namely dislocations and periprosthetic fractures-were the third leading cause of surgical readmissions for THA. For TKA, musculoskeletal conditions-namely pain and hematoma-were the third leading cause of surgical readmissions.

CONCLUSION

Medical complications accounted for half of all TKA readmissions and more than a third of THA readmissions. This could penalize institutions participating in value-based payment programs or dissuade others who are considering participation in such programs.

Accelerated Discharge After Aseptic Revision Total Hip Arthroplasty Does Not Predict Inferior 30-Day Outcomes

BACKGROUND

Perioperative advancements have made outpatient primary total hip arthroplasty (THA) a viable option for patients. This study evaluated the feasibility of expedited discharge after revision THA and compared 30-day outcomes to patients who had prolonged inpatient hospitalizations. The authors hypothesized that expedited discharge would not result in inferior 30-day outcomes.

METHODS

Aseptic revision THAs in a national database were reviewed from 2013 to 2020. THAs were stratified by hospital length of stay (LOS) more or less than 24 hours. Demographics, comorbidities, preoperative laboratory values, American Society of Anesthesiology (ASA) scores, operative times, components revised, 30-day readmissions, and reoperations were compared. Multivariable analyses evaluated predictors of discharge prior to 24 hours, 30-day readmissions, and reoperations. Of 17,044 aseptic revision THAs, 211 were discharged within 24 hours.

RESULTS

Accelerated discharge patients were younger, mean age 63 years (range, 20-92) versus 66 years (range, 18-94) (P < .01) had lower body mass index, mean 28.7 (range, 18.3-46.4) versus 29.9 (range, 17.3-52.5) (P = .01), and ASA scores (ASA, 1-2; 40.4-57.8%) (P < .01). Components revised had no association with LOS (P = .39); however, operative times were shorter and mean 100 minutes (range, 35-369) versus 139 minutes (range, 24-962) (P < .01) in accelerated discharge patients. Accelerated discharge patients had lower readmission rates (P < .01) but no difference in reoperation rates (P = .06).

CONCLUSION

Discharge less than 24 hours after revision THA is a feasible option for the correct patient and further efforts to decrease LOS should be evaluated.

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BACKGROUND

Decreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.

RESULTS

When comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.

CONCLUSION

The unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.

LEVEL OF EVIDENCE

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.

A Machine Learning-Based Online Prediction Tool for Predicting Short-Term Postoperative Outcomes Following Spinal Tumor Resections

Background: Preoperative prediction of short-term postoperative outcomes in spinal tumor patients can lead to more precise patient care plans that reduce the likelihood of negative outcomes. With this study, we aimed to develop machine learning algorithms for predicting short-term postoperative outcomes and implement these models in an open-source web application. Methods: Patients who underwent surgical resection of spinal tumors were identified using the American College of Surgeons, National Surgical Quality Improvement Program. Three outcomes were predicted: prolonged length of stay (LOS), nonhome discharges, and major complications. Four machine learning algorithms were developed and integrated into an open access web application to predict these outcomes. Results: A total of 3073 patients that underwent spinal tumor resection were included in the analysis. The most accurately predicted outcomes in terms of the area under the receiver operating characteristic curve (AUROC) was the prolonged LOS with a mean AUROC of 0.745 The most accurately predicting algorithm in terms of AUROC was random forest, with a mean AUROC of 0.743. An open access web application was developed for getting predictions for individual patients based on their characteristics and this web application can be accessed here: huggingface.co/spaces/MSHS-Neurosurgery-Research/NSQIP-ST. Conclusion: Machine learning approaches carry significant potential for the purpose of predicting postoperative outcomes following spinal tumor resections. Development of predictive models as clinically useful decision-making tools may considerably enhance risk assessment and prognosis as the amount of data in spinal tumor surgery continues to rise.

Racial and Ethnic Disparities in Short-Stay Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to understand racial and ethnic disparities in hospital-based, Medicare-defined outpatient total knee arthroplasty (TKA). We aimed to determine the following: 1) whether there are differences in preoperative characteristics or postoperative outcomes in outpatient TKA between racial/ethnic groups and 2) trends in outpatient TKA volume, based on race/ethnicity.

METHODS

This was a retrospective cohort study of a large national database. Outpatient TKAs performed between 2012 and 2018 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were compared between White, Black, Asian, and Hispanic patients.

RESULTS

Of 54,183 outpatient patients, 85.6% were White, 7.4% Black, 2.6% Asian, and 4.1% Hispanic. Black patients had the highest body mass index, and there were higher rates of diabetes among all minority groups (P < .001). All minority groups were more likely to be discharged to a rehabilitation or a skilled care facility compared to White patients (P < .001). Annual percentage increases in outpatient TKA were most pronounced for Asians and Hispanics and least pronounced among Blacks, when compared to White patients.

CONCLUSION

The outcomes of outpatient TKA are impacted by risk factors that reflect underlying disparities in healthcare. As joint arthroplasties have come off the inpatient-only list and procedures move to ambulatory settings, these disparities will likely magnify and impact outcomes, costs, and access points. Extensive preoperative optimization and interventions that target medical and social factors may help to reduce these disparities in TKA and increase access among minority patients.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians

BACKGROUND

One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old.

METHODS

This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed.

RESULTS

Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days.

CONCLUSION

Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.

The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis

Introduction

As a result of the SARS-CoV-2 (COVID-19) pandemic in 2020, elective surgeries, including total joint arthroplasty (TJA), were suspended nationwide. Concurrent removal of total hip arthroplasty (THA) from the Medicare inpatient-only list posed challenges to the delivery of quality patient care with low payor cost. Therefore, the objective of this study was to compare temporal trends in patient demographics, case volumes, length of stay, and complications following elective THA in the years 2019 to 2020 in the United States.

Methods

The 2019 to 2020 ACS-NSQIP database was queried for elective THA patients. Patients Pre-COVID (2019 and 2020Q1) were compared with post-COVID (2020Q2-Q4). THA utilization, demographics, 30-day complications, and length of stay (LOS) were compared between years. Linear regression evaluated changes in case volumes over time with significance threshold of P < 0.05.

Results

A total of 77,797 patients underwent elective THA in 2019 (n = 43,667) and 2020 (n = 34,130), resulting in a 24.5% decline. Outpatient THA increased in 2020 (35.6%) vs. 2019 (5.7%) (P < 0.001). There was no significant difference in the volume of cases in 2019Q1 through 2019Q4 (P = 0.984). Elective THA volumes declined by 68.8% in 2020Q2, returned to pre-pandemic baseline in 2020Q3, before leveling off at 81.5% of baseline in Q4. Average LOS was significantly shorter in 2020 (1.55 days) vs. 2019 (1.78 days) (P < 0.001) and the proportion of same day discharge (SDD) increased quarterly from 2019 to 2020. There was no significant difference in the total complication rates in 2019 (6.6%) vs. 2020 (6.6%) (P = 0.831).

Discussion

Elective THA precipitously declined during the second quarter of 2020. The combined effect of policy changes and the COVID-19 pandemic resulted in a seven-fold increase in the number of surgeries performed in the outpatient setting in 2020. Rates of SDD doubled over the study period, despite no change in complication rates.

Accelerated discharge after aseptic revision knee arthroplasty is not associated with early readmission and reoperation

Aims

In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

Methods

Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation.

Results

Of 21,610 aseptic revision TKAs evaluated, 530 were discharged within 24 hours. Short-stay patients were younger (63.1 years (49 to 78) vs 65.1 years (18 to 94)), with lower BMI (32.3 kg/m2 (17 to 47) vs 33.6 kg/m2 (19 to 54) and lower ASA grades. Diabetes, chronic obstructive pulmonary disease, hypertension, and cancer were all associated with a hospital stay over 24 hours. Single component revisions (56.8% (n = 301) vs 32.4% (n = 6,823)), and shorter mean operating time (89.7 minutes (25 to 275) vs 130.2 minutes (30 to 517)) were associated with accelerated discharge. Accelerated discharge was not associated with 30-day readmission and reoperation.

Conclusion

Accelerated discharge after revision TKA did not increase short-term complications, readmissions, or reoperations. Further efforts to decrease hospital stays in this setting should be evaluated. Cite this article: Bone Joint J 2022;104-B(12):1323–1328.

RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases

BACKGROUND

Changes to Medicare's Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA.

METHODS

We identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C).

RESULTS

Reviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods.

CONCLUSION

RAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.

Overnight joint replacement surgery: a pilot Australian study

BACKGROUND

With a stretched healthcare system and elective surgery backlog, measures to improve efficiency and decrease costs associated with surgical procedures need to be prioritized. This study compares the benefits of multi-disciplinary involvement in an enhanced recovery after surgery (ERAS) protocol-led overnight model following total hip replacement (THR) and total knee replacement (TKR).

METHODS

Patients in each of two private hospitals undergoing THR or TKR were prospectively enrolled. One hospital (Overnight) was fully committed to the ERAS protocol implementation on all levels and formed the treatment group while in the other hospital (control), patients only had the anaesthetic and operative procedure as part of the ERAS protocol but did not follow the perioperative measures of the protocol. Outcomes on hospital length of stay (LOS), inpatient rehabilitation, functional outcomes, satisfaction, adverse events and readmission rates were investigated.

RESULTS

Median LOS in the Overnight group was significantly smaller than in the control group (1 vs. 3 days, P < 0.0001). The Overnight group had lower rates of inpatient rehabilitation utilization (4% vs. 41.2%, P < 0.0001), similar improvements in functional hip and knee scores and no increased rate of adverse events or readmission. All patients in both groups were satisfied with their treatment.

CONCLUSION

Overnight THR and TKR can safely be performed in the majority of patients, with a multi-disciplinary approach protocol and involvement of all perioperative stakeholders.

Outpatient total knee and hip arthroplasty present comparable and even better clinical outcomes than inpatient operation

Background

The purpose of this study was to compare total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days after outpatient and standard inpatient total knee and total hip arthroplasty (TKA, THA).

Methods

A literature search was conducted from the PubMed, Cochrane Library, and Embase databases for articles published before 20 August 2021. The types of studies included prospective randomized controlled trials, prospective cohort studies, retrospective comparative studies, retrospective reviews of THA and TKA registration databases, and observational case-control studies. Comparisons of interest included total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days. The statistical analysis was performed using Review Manager 5.3.

Results

Twenty studies with 582,790 cases compared relevant postoperative indicators of outpatient and inpatient total joint arthroplasty (TJA) (TKA and THA). There was a significant difference in the total complications at 30 days between outpatient and inpatient THA (p = 0.001), readmissions following TJA (p = 0.03), readmissions following THA (p = 0.001), stroke/cerebrovascular incidents following TJA (p = 0.01), cardiac arrest following TJA (p = 0.007), and blood transfusions following TJA (p = 0.003). The outcomes showed an obvious difference in 90-day total complications between outpatient and inpatient TJA (p = 0.01), readmissions following THA (p = 0.002), and surgical-related pain following TJA (p < 0.001). We did not find significant differences in the remaining parameters.

Conclusion

Outpatient procedures showed comparable and even better outcomes in total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days compared with inpatient TJA for selected patients.

A comparison of functional outcomes following inpatient versus outpatient hip or knee arthroplasty

BACKGROUND

The length of hospital stay after lower limb arthroplasty has rapidly decreased in the last decade, largely in part due to the rise of improved perioperative protocols, but also as a response to the increased economic demand associated with the rapid growth in hip and knee arthroplasty procedures. In line with this, the development of a new pathway after lower limb arthroplasty that allows for the surgery to be performed in an outpatient setting and permits for same-day discharge after the procedure is increasingly being offered. Although costs and complications between the inpatient and outpatient models have been compared, there appears to be little known about the effects on a patient's physical function after undergoing hip or knee outpatient arthroplasty. Therefore, this systematic review aims to explore the available evidence for the effect on functional outcomes following inpatient versus outpatient hip or knee arthroplasty.

METHODS

This systematic review adhered to the PRISMA guidelines and was prospectively registered ( https://osf.io/8bfae/ ). An electronic search of three online databases (PubMed, CINAHL and EMBASE) was conducted to identify eligible studies. All studies investigating inpatient and outpatient comparator groups, for a population of patients undergoing hip or knee arthroplasty, that assessed one or more functional outcomes, were included. A methodological quality appraisal was undertaken for the final studies contained in this review. A narrative synthesis of results is described along with quantitative outcomes presented in tables and figures.

RESULTS

A total of seven studies containing 1,876 participants were included in this review. Four studies assessed a THA population, two assessed TKA and one assessed both. Functional outcomes varied, with 20 different functional outcomes utilised, of which 18 were patient-reported tools. Results of functional outcomes offered mixed support for both inpatient and outpatient pathways.

CONCLUSIONS

The results of this review suggest that outpatient or inpatient pathway selection for hip or knee arthroplasty should not be based on the superiority of functional outcomes alone. However, given there is growing evidence in support of an outpatient pathway in select patients with respect to cost savings and without any increase in complications, it could be proposed that an equivalency of post-operative function between the two settings makes same-day discharge favourable. Publicly registered with Open Science Framework ( https://osf.io/8bfae/ ).

Safety and efficacy of outpatient hip and knee arthroplasty: a systematic review with meta-analysis

INTRODUCTION

This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways.

MATERIALS AND METHODS

An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways-following hip and/or (partial) knee arthroplasty-were included. Included studies were assigned-based on OJA definition-to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate.

RESULTS

A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41-0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02.

CONCLUSION

OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.

Sex Differences in Utilization and Perioperative Outcomes of Arthroscopic Rotator Cuff Repair

Background

As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

Results

Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

Conclusion

Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Risk Factors for Delayed Discharge and Adverse Outcomes Following Outpatient Billed Total Knee Arthroplasty

BACKGROUND

The volume of outpatient total knee arthroplasty (TKA) has increased with advances in perioperative protocols, patient selection, and recent policy changes regarding insurance authorization. This study analyzed 30-day outcomes from a national database to better understand risk factors for delayed discharge (length of stay [LOS] ≥1), readmission, and reoperation after outpatient TKA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was utilized to collect TKA (CPT 27447) billed as outpatient surgery performed from 2013 to 2018. Patient demographics, comorbidities, and short-term outcomes were collected and compared in LOS 0 versus LOS ≥1 cohorts. Subgroup analysis was completed for TKA performed in 2018, after the Center for Medicare Services removal of TKA from the inpatient-only list.

RESULTS

A total of 13,669 patients had outpatient TKA performed from 2013 to 2018. Most patients had LOS ≥1 day (77.1%). The LOS 0 cohort demonstrated a lower 30-day readmission rate (1.8%) compared to LOS ≥1 (2.8%), P > .01. Both groups demonstrated a low 30-day reoperation rate, LOS 0 (0.7%) and LOS ≥1 (1.1%), P = .05. Regression analysis demonstrated risk factors for LOS ≥1 day included COPD, ASA ≥3, age >75, and BMI >35 kg/m². Regression analysis demonstrated male gender, age >75, ASA ≥3, and albumin <3.5 g/dL were risk factors for readmission. Hypertension was a risk factor for 30-day reoperation.

CONCLUSION

Risk factors for LOS ≥1 day include age >75, ASA ≥3, BMI >35 kg/m². In addition, BMI >35 kg/m² was a risk factor for readmission and reoperation. These findings reinforce appropriate patient selection when considering outpatient TKA.

Same-day discharge arthroplasty has a higher overall complications rate than fast-track arthroplasty: a systematic review and meta-analysis

BACKGROUND

Published studies have reported many inconsistent results regarding the comparison of same-day discharge total joint arthroplasty (TJA) and inpatient TJA. More notably, many recent studies comparing same-day discharge TJA with fast-track TJA presented higher rates of complications for same-day discharge TJA, which raises concerns about the safety of same-day discharge TJA.

METHODS

We systematically searched the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases up to June 2020 for studies comparing mortality, readmission, and complications in same-day discharge and inpatient total hip or knee arthroplasty. Studies that used inpatient TJA as the control could be further divided into fast-track inpatient TJA (length of stay [LOS] ≤ 2 days) and traditional inpatient TJA (no restrictions on LOS). Relative risks were pooled to compare the outcomes of the same-day discharge group and the control group.

RESULTS

According to selection criteria and quality assessment, 14 studies including 222,766 cases were identified. There was no significant difference in the risk of mortality (RR = 1.42, CI [0.67, 3.01]) or readmission (RR = 0.93, CI [0.79, 1.10]) between same-day discharge TJA and inpatient TJA. Compared with fast-track TJA, the rate of overall complications in same-day discharge TJA was significantly higher (RR = 1.67, CI [1.45, 1.93]), while the rates of overall complications were similar between same-day discharge and traditional inpatient TJA (RR = 0.83, CI [0.67, 1.03]).

CONCLUSION

The overall safety of same-day discharge TJA is satisfactory; however, more complications were detected in same-day discharge TJA than that in fast-track TJA. Complications in same-day discharge TJA might be underestimated in some previous studies taking long-staying inpatient TJA as control. Being more cautious about complications is necessary in the care of same-day discharge TJA, and extensive prospective studies are needed to explore the optimized option that weighs both cost and complications.

Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study

Background

Neuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given the selection of healthier patients.

Objective

To compare the effects of neuraxial versus general anesthesia on outcomes following ambulatory hip and knee arthroplasty.

Methods

Multicentered retrospective cohort study in ambulatory hip or knee arthroplasty patients between January 2017 and December 2019. Primary endpoint examined 30-day major postoperative complications (mortality, myocardial infarction, deep venous thromboembolism, pulmonary embolism, stroke, and acute renal failure).

Results

Of 11 523 eligible patients identified, 10 003 received neuraxial anesthesia, while 1520 received general anesthesia. 30-day major complications did not differ between neuraxial anesthesia and general anesthesia groups (1.8% vs 2.3%; aOR=0.85, CI: 0.56 to 1.27, p=0.39). There was no difference in 30-day minor complications (surgical site infection, pneumonia, urinary tract infection; 3.3% vs 4.1%; aOR=0.83, CI: 0.62 to 1.14, p=0.23). The neuraxial group demonstrated reduced pain and analgesia requirements and had less postoperative nausea and vomiting (PONV). Median recovery room length of stay was shorter by 52 min in the general anesthesia group, but these patients were more likely to fail same day discharge (33% vs 23.4%; p<0.01).

Conclusion

Anesthesia type was not associated with an increased risk for complications. However, neuraxial anesthesia improved outcomes that predict readiness for discharge: patients had less pain, required less opioids, and had a lower incidence of PONV, thus improving the rate of same day discharge.

Trial registration number

NCT04203732.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty

Background:

The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated.

Methods:

A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA.

Results:

A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus.

Conclusion:

From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort.

Level of Evidence

Level III, retrospective cohort study.

Complications of total hip or knee arthroplasty are not significantly more common after ambulatory surgery than after in-patient surgery and enhanced recovery: A case-control study with propensity-score matching

BACKGROUND

Reluctance to perform total hip arthroplasty (THA) and total knee arthroplasty (TKA) on an ambulatory basis stems from concern that complications might be more common than with enhanced recovery after surgery (ERAS). The objective of this study was to compare the risks of complications, readmission, and reoperation with these two strategies.

HYPOTHESIS

The complication rate is significantly higher after ambulatory surgery (AS) than with ERAS.

MATERIAL AND METHODS

Consecutive patients who underwent primary unilateral THA or TKA by two senior surgeons to treat a non-traumatic condition between July 2016 and December 2019 were eligible. We developed a propensity score, which we used to individually match each of the 91 patients managed by AS to the 91 patients managed with ERAS (control group). Follow-up was 3 months. The primary outcome was development of a complication within the first 3 months. Secondary outcomes were complication severity as classified according to Clavien-Dindo, re-admissions within 3 months, and re-operations within 3 months.

RESULTS

Complications were not significantly more common after AS than with ERAS (15% and 11%, respectively, p=0.38). No significant differences were found between the two groups for complication severity (2.9±0.5 versus 2.6±0.8), proportion of re-admitted patients (14% versus 9%), or proportion of re-operated patients (14% versus 9%).

DISCUSSION

The risk of complications was not higher after AS than with ERAS. Reluctance to perform AS due to concern about safety does not seem justified by the evidence.

LEVEL OF EVIDENCE

III, propensity score-matched case-control study.

Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?

BACKGROUND

To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians.

METHODS

This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb.

RESULTS

Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01).

CONCLUSION

The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates

STUDY DESIGN

Retrospective cohort comparison study.

OBJECTIVE

The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

SUMMARY OF BACKGROUND DATA

Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF.

MATERIALS AND METHODS

Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups.

RESULTS

In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%).

CONCLUSIONS

The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures.

LEVEL OF EVIDENCE

Level III.

Robotic-arm-assisted Knee Arthroplasty Associated With Favorable In-hospital Metrics and Exponentially Rising Adoption Compared With Manual Knee Arthroplasty

BACKGROUND

Technology-assisted knee arthroplasty (KA), including robotic-arm-assisted knee arthroplasty (RA-KA) and computer-assisted (CA-KA) knee arthroplasty, was developed to improve surgical accuracy of implant positioning and alignment, which may influence implant stability, longevity, and functional outcomes. However, despite increased adoption over the past decade; its value is still to be determined.

QUESTIONS/PURPOSE

This study aimed to compare robotic-arm (RA)-KA, CA-KA, and manual (M)-KA regarding (1) in-hospital metrics (length of stay [LOS], discharge disposition, in-hospital complications, and hospitalization-episode costs), (2) characterize annual utilization trends, and (3) future RA-KA and CA-KA utilization projections.

METHODS

National Inpatient Sample was queried for primary KAs (unicompartmental/total; 2008 to 2018). KAs were classified by modality (M-KA/CA-KA/RA-KA) using International Classification of Disease-9/10 codes. A propensity score-matched comparison of LOS, discharge disposition, in-hospital complications (implant-related mechanical or procedure-related nonmechanical complications), and costs was conducted. Trends and projected utilization rates were estimated.

RESULTS

After propensity score matched to their respective M-KA cohorts, RA-KA and CA-KA exhibited shorter LOS (RA-KA versus M-KA: 2.0 ± 1.4 days versus 2.5 ± 1.8 days; P < 0.001; CA-KA versus M-KA: 2.7 ± 1.4 days versus 2.9 ± 1.6 days; P < 0.001) and in-hospital implant-related mechanical complications (P < 0.05, each). RA-KA demonstrated lower nonhome discharge (P < 0.001) and in-hospital procedure-related nonmechanical complications (P = 0.005). RA-KA had lower in-hospital costs ($16,881 ± 7,085 versus $17,320 ± 12,820; P < 0.001), whereas CA-KA exhibited higher costs ($18,411 ± 7,783 versus $17,716 ± 8,451; P < 0.001). RA-KA utilization increased from <0.1% in 2008 to 4.3% in 2018. CA-KA utilization rose temporarily to 6.2% in 2014, then declined to pre-2010 levels in 2018 (4.5%). Projections indicate that RA-KA and CA-KA will represent 49.9% (95% confidence interval, 41.1 to 59.9) and 6.2% (95% confidence interval, 5.3% to 7.2%) of KAs by 2030.

DISCUSSION

RA-KA may provide value through improving in-hospital metrics and mitigating net costs. Similar advantages may not be reliably attainable with CA-RA. Because RA-KA is projected to reach half of all knee arthroplasties done in the United States by 2030, further cost analyses and long-term studies are warranted.

Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization

INTRODUCTION

Migration of total knee arthroplasty (TKA) procedures from the inpatient setting to outpatient venues, especially freestanding ambulatory surgery centers (ASCs), requires the use of reliable patient selection algorithms and standardized perioperative pathways to facilitate favorable outcomes for patients.

METHODS

This retrospective chart review included consecutive TKA procedures performed over a 5-year period between January 2014 and January 2019 at 2 freestanding ASCs. The patient selection algorithm was developed on the basis of patient comorbidities to minimize the potential for adverse events. All procedures were performed by one of eight orthopedic surgeons who were identified a priori as adhering to similar multimodal pain management regimens, including the use of spinal anesthesia, general or monitored-care anesthesia, adductor canal blocks, pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen, and oxycodone on an as-needed basis. Outcomes, including surgical complications, healthcare resource utilization (HCRU), and patient satisfaction, were measured before discharge and at a 90-day follow-up visit.

RESULTS

Four hundred thirty-nine TKA procedures in 386 patients were identified for inclusion. Of these patients, 115 (29.8%) were performed in patients with the American Society of Anesthesiologists physical status IIIa. Mean (standard deviation) length of stay at the ASC was 500 (107) minutes, including 136 (47) minutes of surgery and 201 (78) minutes to ambulation. The overall rates of surgical complications and 90-day hospital admissions were low (1.4% and 0.7%, respectively), as was the need for additional HCRU, including additional surgical procedures related to index surgery, emergency department visits, and unplanned clinic visits or calls. At the 90-day follow-up visit, 96% of patients reported being pleased with their outcomes.

DISCUSSION

With careful patient selection, standardized perioperative pathways, and multimodal analgesia protocols, TKA procedures can be performed in the ASC setting with low complication rates, minimal postdischarge HCRU, and high rates of patient satisfaction.

LEVEL OF EVIDENCE

III.

Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3

BACKGROUND

Although safety in same-day discharge total joint arthroplasty (TJA) has been reported, findings are limited to healthier patients, specific surgeons, and/or specific institutions. Indications for same-day discharge TJA have expanded to include patients with multiple comorbidities; however, safety in this specific patient population remains unknown. Therefore, we sought to compare the risk of 90-day adverse events in higher-risk patients undergoing same-day discharge versus inpatient TJA.

METHODS

The Kaiser Permanente Total Joint Replacement Registry was utilized to conduct a cohort study. All patients with an American Society of Anesthesiologists (ASA) classification of ≥3 who underwent primary elective TJA for osteoarthritis from 2017 through 2018 were identified. The risk of 90-day adverse events (i.e., emergency department visits, unplanned readmissions, complications, and mortality) was evaluated with use of propensity score-weighted Cox proportional hazard regression including noninferiority testing with a margin of 1.10.

RESULTS

The cohort included a total of 5,250 patients who underwent total hip arthroplasty and 9,752 patients who underwent total knee arthroplasty, of whom 1,742 (33.2%) and 3,283 (33.7%) had same-day discharge, respectively. Same-day discharge hip arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (hazard ratio [HR], 0.73; 1-sided HR 95% upper bound [UB], 0.84), readmissions (HR, 0.47; 95% UB, 0.61), and complications (HR, 0.63; 95% UB, 0.75); we did not have evidence of noninferiority for mortality (HR, 0.84; 95% UB, 1.97). Same-day discharge knee arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (HR, 0.79; 95% UB, 0.87), readmission (HR, 0.80; 95% UB, 0.95), complications (HR, 0.72; 95% UB, 0.82), and mortality (HR, 0.53; 95% UB, 1.03).

CONCLUSIONS

We found that same-day discharge TJA did not increase the risk of emergency department visits, unplanned readmissions, and complications compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge TJA in the hospital setting while maintaining safety.

LEVEL OF EVIDENCE

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

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

Background

As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care.

Methods

Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time.

Results

A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31).

Conclusion

When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.

Trends in outpatient versus inpatient total shoulder arthroplasty over time

Background

The purpose of this study was to investigate the safety of outpatient and inpatient total shoulder arthroplasty (TSA) and to investigate changes over time.

Methods

Patients undergoing primary TSA during 2006-2019 as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Patients were divided into an early cohort (2006-2016, 12,401 patients) and a late cohort (2017-2019, 12,845 patients). Outpatient procedures were defined as those discharged on the day of surgery. Patient comorbidities and rate of adverse events within 30 days postoperatively were compared with adjustment for baseline characteristics using standard multivariate regression.

Results

There was a significant reduction in complications over time when considering all cases (5.69% in the early cohort vs. 3.67% in the late cohort, adjusted relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.58-0.73, P < .001). The rate of complications decreased over time among inpatients (5.80% vs. 3.90%, adjusted RR = 0.68, 95% CI = 0.60-0.76, P < .001). However, there was no difference in the rate of complications among outpatients over time (1.98% vs. 1.38%, adjusted RR = 0.64, 95% CI = 0.28-1.47, P = .293). There were significantly more complications among inpatients vs. outpatients in both the early and late cohorts (early: 5.80% vs. 1.98%, adjusted RR = 2.57, 95% CI = 1.24-5.34, P = .011, late: 3.90% vs. 1.38%, adjusted RR = 2.28, 95% CI = 1.39-3.74, P = .001). TSA became more common in elderly patients over 70 years of age over time in both the inpatient and outpatient cohorts, whereas fewer young patients (aged 18-59 years) underwent TSA in the late cohorts than in the early cohorts for both the inpatient and outpatient samples (P < .001).

Conclusion

The overall complication rate of TSA has decreased over time as outpatient TSA has become increasingly common. When contemporary data are examined, the complication rate of outpatient procedures has remained constant over time while that of inpatient procedures decreased, despite the changing demographics of patients undergoing TSA. This indicates that outpatient TSA remains a safe procedure as patient selection criteria have evolved, while the safety of inpatient TSA continues to improve.

Clinical and Administrative Databases Used in Lower Extremity Arthroplasty Research

BACKGROUND

The use of national databases in lower extremity arthroplasty research has grown rapidly in recent years. We aimed to better characterize available databases by: (1) quantifying the number of these studies in the highest impact arthroplasty journals; (2) comparing respective sample sizes; and (3) contrasting their measured variables/outcomes.

METHODS

An extensive literature search was conducted to identify all database studies in the top 12 highest impact factor journals that published arthroplasty research between January 1, 2018 and December 31, 2019. A total of 5070 publications were identified. These studies were sorted by both database utilized and journal published. Tables were constructed to compare/contrast databases by metrics and measured outcome parameters including coding, patient sample size, preoperative comorbidities, postoperative complications, and limitations/barriers to their use.

RESULTS

Four hundred twenty-six database studies (8.4%, range 0.4%-29.7% per journal) were identified, of which 139 were from non-English-speaking arthroplasty databases. Among English-speaking arthroplasty databases, the 5 most common sources were National Surgical Quality Improvement Project (n = 72), Medicare (n = 62, 39 from Medicare Claims and 23 from PearlDiver), Nationwide Inpatient Sample (n = 35), PearlDiver non-Medicare private insurance (n = 18), and Statewide Planning and Research Cooperative System (n = 18). Metrics, outcome parameters, and features of commonly used registries were reviewed.

CONCLUSION

Database studies constitute an important part of arthroplasty-specific orthopedic research. Their use will continue to grow in the future, and it would be beneficial for clinicians/researchers to be aware of and familiarize themselves with their features to understand which are most appropriate for their work.