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Ohmori T, Fraval A, Hozack WJ. Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained. J Arthroplasty 2024; 39:2311-2315. [PMID: 38649063 DOI: 10.1016/j.arth.2024.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND This study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. METHODS A consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). RESULTS The mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. CONCLUSIONS Our study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.
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Affiliation(s)
- Takaaki Ohmori
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Andrew Fraval
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William J Hozack
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Jayaram RH, Day W, Gouzoulis MJ, Zhu JR, Grauer JN, Rubin LE. Risk Factors for Perioperative Nerve Injury Related to Total Hip Arthroplasty. Arthroplast Today 2024; 28:101440. [PMID: 39139361 PMCID: PMC11320433 DOI: 10.1016/j.artd.2024.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/23/2024] [Accepted: 05/15/2024] [Indexed: 08/15/2024] Open
Abstract
Background Nerve injury following total hip arthroplasty (THA) is a rare but serious adverse event. While prior studies have reported risk factors for nerve injury related to THA, they are limited to institutional data or small sample sizes. The current study aimed to leverage a large, national database to assess independent risk factors for sustaining nerve injury with THA. Methods The 2010-2021 PearlDiver M157 database was queried for adult THA cases. Those with nerve injury within 90 days of THA were identified. Patient age, sex, body mass index (BMI), Elixhauser comorbidity index (ECI), fracture indication, and surgery type (index vs revision) were assessed for correlation with nerve injury by multivariate analyses. Results Out of 750,695 THAs, 2659 (0.35%) had nerve injuries. Multivariate analysis revealed independent predictors of nerve injury in decreasing odds ratio (OR) order to include: revision procedure (OR: 2.13), female sex (OR 1.35), ECI (ECI 1-2 [OR 1.27], ECI 3-4 [OR 1.43], and ECI ≥5 [OR 1.59]) and age (OR 1.02 per decade decrease) (P < .05 for each). Pertinent negatives by multivariate analysis included underweight BMI (<20), and fracture indication. Individuals with morbidly obese BMI status (≥35) had a decreased risk of nerve injury (OR 0.84, P = .019). Conclusions THA-related nerve injury was found to be low at 0.35%. Factors independently associated with this adverse outcome were defined, of which the greatest risk was seen in revision procedures. These risk factors, derived from the largest cohort to date, may be helpful for risk stratification and patient counseling.
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Affiliation(s)
- Rahul H. Jayaram
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Wesley Day
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael J. Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Justin R. Zhu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Lee E. Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Buchanan MW, Gibbs B, Ronald AA, Novikov D, Yang A, Salavati S, Abdeen A. Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital? Clin Orthop Relat Res 2024; 482:1442-1451. [PMID: 38564795 PMCID: PMC11272343 DOI: 10.1097/corr.0000000000003054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. QUESTIONS/PURPOSES When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? METHODS An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. RESULTS After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). CONCLUSION Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Michael W Buchanan
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Brian Gibbs
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Andrew A Ronald
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - David Novikov
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Allen Yang
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Seroos Salavati
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Ayesha Abdeen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
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Mika AP, Mulvey HE, Engstrom SM, Polkowski GG, Martin JR, Wilson JM. Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty? J Knee Surg 2024; 37:664-673. [PMID: 38442904 DOI: 10.1055/s-0044-1782233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.
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Affiliation(s)
- Aleksander P Mika
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hillary E Mulvey
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen M Engstrom
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory G Polkowski
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Ryan Martin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Gong MF, McElroy MJ, Li WT, Finger LE, Shannon M, Gabrielli AS, Tisherman RF, O'Malley MJ, Klatt BA, Plate JF. Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty. J Arthroplasty 2024; 39:1468-1473. [PMID: 38040065 DOI: 10.1016/j.arth.2023.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. METHODS A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. RESULTS Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. CONCLUSIONS The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matthew F Gong
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark J McElroy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William T Li
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Logan E Finger
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael Shannon
- The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alexandra S Gabrielli
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert F Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael J O'Malley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian A Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Keulen MH, Bemelmans YF, Boonen B, Hendrickx RP, Heyligers IC, Schotanus MG. Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty. Arthroplast Today 2024; 26:101343. [PMID: 38450396 PMCID: PMC10915506 DOI: 10.1016/j.artd.2024.101343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/04/2023] [Accepted: 02/03/2024] [Indexed: 03/08/2024] Open
Abstract
Background Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways. Methods A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117). Results No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001). Conclusions Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.
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Affiliation(s)
- Mark H.F. Keulen
- Faculty of Health, Medicine and Life Sciences, School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands
| | - Yoeri F.L. Bemelmans
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands
| | - B. Boonen
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands
| | - Roel P.M. Hendrickx
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands
| | - Ide C. Heyligers
- Faculty of Health, Medicine and Life Sciences, School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands
| | - Martijn G.M. Schotanus
- Department of Orthopaedic Surgery and Traumatology, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands
- Faculty of Health, Medicine & Life Sciences, School of Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, The Netherlands
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Mika AP, Martin JR, Engstrom SM, Polkowski GG, Wilson JM. Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty. J Bone Joint Surg Am 2023; 105:1519-1526. [PMID: 37459402 DOI: 10.2106/jbjs.23.00209] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA). METHODS Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics. CONCLUSIONS The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.
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Affiliation(s)
- Aleksander P Mika
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Moore MC, Dubin JA, Bains SS, Douglas S, Hameed D, Nace J, Delanois RE. Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications. J Orthop 2023; 44:1-4. [PMID: 37601159 PMCID: PMC10432695 DOI: 10.1016/j.jor.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
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.
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Affiliation(s)
- Mallory C. Moore
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Scott Douglas
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Daniel Hameed
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - James Nace
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ronald E. Delanois
- Lifebridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:946-962. [PMID: 35951077 PMCID: PMC9366132 DOI: 10.1007/s00167-022-07094-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/24/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of day-case unicompartmental knee arthroplasty (UKA) by assessment of successful same-day discharge (SDD), readmission, complication and reoperation rates in the recent literature. METHODS For this systematic review and meta-analysis, PubMed, Embase and Cochrane Library were comprehensively searched to identify all eligible studies reporting outcomes of day-case UKA. Studies with intended same-day home discharge after UKA were included. A meta-analysis of proportions, using a random-effects model, was performed to estimate overall rates of successful SDD and adverse events. Subgroup analyses were performed for studies including selected patients (i.e., patients had to meet certain patient-specific criteria to be eligible for day-case UKA) and unselected patients (i.e., no additional criteria for day-case UKA), as well as for clinical and registry-based studies. Additional outcomes included reasons for the failure of SDD and patient satisfaction. RESULTS A total of 29 studies and 9694 patients were included with a mean age of 66 ± 9 years and mean follow-up of 59 days (mean range 30-270 days). Based on 24 studies (2733 patients), the overall successful SDD rate was 88% (95% confidence interval [CI] 80-92). These rates were 91% (95% CI 84-95) across studies with selected patients and 76% (95% CI 55-89) across studies with unselected patients. Overall readmission, complication and reoperation rates were 3% (95% CI 1.9-4.4), 4% (95% CI 2.8-5.2) and 1% (95% CI 0.8-1.3), respectively. Inability to mobilize, nausea and uncontrolled pain were frequently reported reasons for failed SDD. The overall patient satisfaction rate was 94%. CONCLUSION This systematic review with meta-analysis found an overall successful SDD rate of 88% after UKA in a heterogeneous cohort of selected and unselected patients. Readmission, complication and reoperation rates suggest UKA can be performed safely and effectively as a same-day discharge procedure. LEVEL OF EVIDENCE Level IV, systematic review of level III and IV studies.
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10
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Ambulatory anesthesia and discharge: an update around guidelines and trends. Curr Opin Anaesthesiol 2022; 35:691-697. [PMID: 36194149 DOI: 10.1097/aco.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia. RECENT FINDINGS Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery. SUMMARY The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.
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Keulen MH, Most J, Schotanus MG, van Haaren EH, Heyligers IC, Boonen B. Orthopaedic surgeons' perspective on the implementation of outpatient hip and knee arthroplasty - Results of a nationwide survey. J Clin Orthop Trauma 2022; 29:101873. [PMID: 35542179 PMCID: PMC9079766 DOI: 10.1016/j.jcot.2022.101873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022] Open
Abstract
Background Outpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA. Methods A 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123). Results Twenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables). Conclusion One in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.
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Affiliation(s)
- Mark H.F. Keulen
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
| | - Jasper Most
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
| | - Martijn G.M. Schotanus
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
- School of Care and Public Health Research Institute, Faculty of Health, Medicine & Life Sciences, Maastricht University Medical Centre, P. Debyelaan 25, 6202, AZ Maastricht, the Netherlands
| | - Emil H. van Haaren
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
| | - Ide C. Heyligers
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
- School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER Maastricht, the Netherlands
| | - Bert Boonen
- Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Dr. H. van der Hoffplein 1, 6162, BG Geleen, the Netherlands
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Singh V, Nduaguba AM, Macaulay W, Schwarzkopf R, Davidovitch RI. Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes. Arch Orthop Trauma Surg 2022; 142:861-869. [PMID: 34075486 DOI: 10.1007/s00402-021-03983-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay. MATERIALS AND METHODS We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences. RESULTS A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts. CONCLUSION Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, The New York Hip Institute, 485 Madison Ave. 8th Floor, New York, USA
| | - Afamefuna M Nduaguba
- Department of Orthopedic Surgery, NYU Langone Health, The New York Hip Institute, 485 Madison Ave. 8th Floor, New York, USA
| | - William Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, The New York Hip Institute, 485 Madison Ave. 8th Floor, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, The New York Hip Institute, 485 Madison Ave. 8th Floor, New York, USA
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, The New York Hip Institute, 485 Madison Ave. 8th Floor, New York, USA.
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Oberfeld J, von Hertzberg-Boelch SP, Weissenberger M, Holzapfel BM, Rudert M, Jakuscheit A. Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients. J Arthroplasty 2021; 36:3686-3691. [PMID: 34284936 DOI: 10.1016/j.arth.2021.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients. METHODS 167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m2) and severely diseased patients (ASA≥3). RESULTS TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12). CONCLUSION Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.
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Affiliation(s)
- Jan Oberfeld
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | | | - Manuel Weissenberger
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Boris M Holzapfel
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
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Wignadasan W, Thompson JW, Ibrahim M, Kayani B, Magan A, Haddad FS. Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway. Ann R Coll Surg Engl 2021; 104:165-173. [PMID: 34323112 DOI: 10.1308/rcsann.2021.0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.
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Affiliation(s)
| | - J W Thompson
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - M Ibrahim
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - B Kayani
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - A Magan
- University College London Hospitals, UK
| | - F S Haddad
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
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