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Katragadda BC, Suresh A, Azeez A. Can an Enhanced Recovery Protocol Result in a Safe and Effective Outpatient Simultaneous Bilateral Total Knee Arthroplasty? J Arthroplasty 2024; 39:1679-1684. [PMID: 38320663 DOI: 10.1016/j.arth.2024.01.056] [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: 09/19/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Outpatient total knee arthroplasty (OP TKA) is found to benefit patients as well as the health care system. Studies on OP TKA have been limited to unilateral total knee arthroplasty (TKA). This study aimed to determine if enhanced recovery after surgery (ERAS) protocols can result in performing simultaneous bilateral TKA (SBTKA) safely and effectively in the OP setting. METHODS This retrospective study compared patients who underwent SBTKA in an OP setting (OP group, n = 100) using an ERAS protocol from April 1, 2021, to June 30, 2022, and a propensity-matched historical group (inpatient group, n = 100) operated in an inpatient setting via conventional protocol from July 1, 2019, to June 30, 2020. The complication rate, readmission rate, visual analog score (VAS), range of motion (ROM), and Knee Society Score (KSS) were compared between the groups in the early postoperative and follow-up periods up to 1 year. RESULTS We found a comparable complication rate (4 versus 7%, P = .4) and readmission rate (2 versus 3%, P = .7). The VAS score was significantly lower in the OP group on day 1, day 2, day 7, and day 14 postsurgery (P < .001). The KSS and ROM were significantly better in the OP group after 14 days (P < .001). The VAS, KSS, and ROM were comparable between the groups at 1 month and later follow-up periods (P > .05). CONCLUSIONS An ERAS protocol in SBTKA patients resulted in safe same-day discharge with better early functional outcomes compared with conventional practices. The results from similar future studies can alleviate surgeon and patient concerns about OP TKA.
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Affiliation(s)
- Bharat C Katragadda
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
| | - Anoop Suresh
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
| | - Arshad Azeez
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
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2
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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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3
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Sumbal R, Ashkar A, Sumbal A, Abdul Moiz M. Reasons and Risk Factors for Same-Day Discharge Following Total Joint Arthroplasty: A Systematic Review. Arthroplast Today 2024; 27:101363. [PMID: 38665390 PMCID: PMC11043888 DOI: 10.1016/j.artd.2024.101363] [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: 09/21/2023] [Revised: 02/12/2024] [Accepted: 02/25/2024] [Indexed: 04/28/2024] Open
Abstract
Background Nowadays, emphasis is being given to same-day discharge (SDD) following total joint arthroplasty. Unfortunately, despite a high degree of success, there are instances of failed SDD. Therefore, we aim to conduct a systematic review to evaluate factors contributing to failed SDD after total joint arthroplasty. Methods Pubmed, Scopus, Cochrane, and Google Scholar were searched. The Newcastle Ottawa score was used for the quality assessment of selected studies. All the studies were evaluated through a narrative synthesis. A total of 11 studies evaluating 157,045 patients were selected. The mean age of patients was 62.5 years. Results Elderly patients (odds ratio [OR] 1.01 to OR 3.13), women (OR 1.63 to OR 2.87), non-white race (OR 1.31 to OR 2.19), hypertension (OR 1.11 to OR 1.41), diabetes (OR 1.25 to OR 4.06), cardiovascular diseases (OR 1.67 to OR 12.06), chronic obstructive pulmonary disease (OR 1.30 to OR 1.96), bleeding disorders (OR 1.32 to OR 1.52), obesity (OR 1.35 to OR 3.30), steroid use (OR 1.23 to OR 1.52), late procedure start time (OR 1.22 to OR 5.16), higher postoperative pain (OR 1.93 to OR 5.85), high American Society of Anesthesiologists score (OR 0.92 to OR 3.50) were major predictors of failed SDD. Conclusions Through our review, we highlighted that elderly patients, women, non-white race, hypertension, diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, bleeding disorders, obesity, steroid use, late procedure start time, higher postoperative pain, and high American Society of Anesthesiologists score were major predictors of a failed SDD. Many factors evaluated in our study were presented in one or two studies only; therefore, high-quality studies are required to supplement our findings.
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Affiliation(s)
- Ramish Sumbal
- Dow Medical College, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Anusha Ashkar
- Dow Medical College, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Anusha Sumbal
- Dow Medical College, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Muhammad Abdul Moiz
- Dow Medical College, Dow University of Health Sciences, Karachi, Sindh, Pakistan
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4
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Charron B, Bolz N, Lanting B, Vasarhelyi E, Howard J. Short-Term (90 Days) Clinical Outcomes Following the Day of Surgery Conversion of Inpatient to Same-Day Hip and Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00552-7. [PMID: 38830428 DOI: 10.1016/j.arth.2024.05.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND The incidence of total joint arthroplasty is increasing, with added emphasis on shifting care towards outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion. METHODS We identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a two-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including re-operation, re-admission, and emergency room visits within a 90-day post-operative period. RESULTS We identified a total of 80 patients who converted from inpatient to outpatient surgery over a two-year interval. Over the first 90 days post-operatively four (5%) patients were readmitted: two (2.5%) for medical complications and two (2.5%) for re-operation. There were two (2.5%) re-operations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were five (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of five (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission. CONCLUSIONS Hospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.
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Affiliation(s)
- Brynn Charron
- London Health and Sciences Centre, University Hospital, Division of Orthopaedic Surgery, 339 Windermere Rd, London, ON, N6A 5A5
| | - Nicholas Bolz
- London Health and Sciences Centre, University Hospital, Division of Orthopaedic Surgery, 339 Windermere Rd, London, ON, N6A 5A5
| | - Brent Lanting
- London Health and Sciences Centre, University Hospital, Division of Orthopaedic Surgery, 339 Windermere Rd, London, ON, N6A 5A5
| | - Edward Vasarhelyi
- London Health and Sciences Centre, University Hospital, Division of Orthopaedic Surgery, 339 Windermere Rd, London, ON, N6A 5A5
| | - James Howard
- London Health and Sciences Centre, University Hospital, Division of Orthopaedic Surgery, 339 Windermere Rd, London, ON, N6A 5A5.
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5
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Evans WS, Ziemba-Davis M, Buller LT, Meneghini RM. Efficacy and Safety of Catheter Interventions for Postoperative Urinary Retention After Primary Hip and Knee Total Joint Arthroplasty. J Am Acad Orthop Surg 2024:00124635-990000000-00997. [PMID: 38781355 DOI: 10.5435/jaaos-d-23-01211] [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: 12/14/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Postoperative urinary retention (POUR) is a common barrier to rapid-discharge hip and knee total joint arthroplasty (TJA). We evaluated the efficacy and safety of catheterization intervention methods for POUR before and after discharge. METHODS A total of 1,659 primary TJAs were retrospectively reviewed. POUR resolutions before and after discharge were evaluated relative to catheterization type and other covariates. Complications before and within 90 days of discharge were quantified. A total of 113 POUR cases comprised the analysis sample of 76 hips and 37 knees in 51 women and 62 men with an average age and body mass index of 68.6 (range 22 to 92) years and 31.7 (range 16 to 49) kg/m2. RESULTS POUR resolved before discharge for 82.3% (93/113) of patients, with equivalent resolution rates for intermittent catheterization alone (84.2%, 32/38) compared with indwelling catheterization with or without intermittent catheterization (82.6%, 57/69, P < 0.999), equivalent time to resolution (P = 0.319), and no difference in complication rates (P = 0.999). Complication rates within 90 days of discharge were higher for patients treated with indwelling catheters before discharge (P = 0.049). Resolution before discharge was more likely with increasing body mass index (P = 0.026) and less likely for patients with a history of urinary retention (P = 0.033). 60 percent (12/20) of patients with unresolved POUR were discharged with self-intermittent catheterization and 40% (8/20) with indwelling catheters, with no differences in efficacy and safety based on the catheterization type (P = 0.109). DISCUSSION Before discharge, we observed equivalent resolution rates and equivalent time to resolution for indwelling and intermittent catheterization alone without compromising patient safety. Intermittent catheterization is favored, however, because in situ catheter exposure is dramatically reduced and postdischarge complication rates are lower. Additional research is needed to develop evidence-based POUR guidelines for outpatient TJA.
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Affiliation(s)
- William S Evans
- From the Department of Graduate Medical Education, Indiana University School of Medicine, Indianapolis, IN (Evans), Indiana University Health Multispecialty Musculoskeletal Center, Carmel, IN (Ziemba-Davis), Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN (Buller, and Meneghini)
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Danielsen O, Varnum C, Jensen CB, Jakobsen T, Andersen MR, Bieder MJ, Overgaard S, Jørgensen CC, Kehlet H, Gromov K, Lindberg-Larsen M. Implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting. Acta Orthop 2024; 95:219-224. [PMID: 38715473 PMCID: PMC11077343 DOI: 10.2340/17453674.2024.40185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/14/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND AND PURPOSE Length of hospital stay after hip and knee arthroplasty is about 1 day in Denmark with few patients discharged on the day of surgery. Hence, a protocol for multicenter implementation of discharge on day of surgery has been instituted. We aimed to describe the implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting. METHODS We performed a prospective multicenter study from 7 public hospitals across Denmark. Patients were screened using well-defined in- and exclusion criteria and were discharged on day of surgery when fulfilling functional discharge criteria. The study period was from September 2022 to February 2023 with variable start of implementation. Data from the same centers in a 6-month period before the COVID pandemic from July 2019 to December 2019 was used for baseline control. RESULTS Of 2,756 primary hip and knee arthroplasties, 37% (95% confidence interval [CI] 35-39) were eligible (range 21-50% in centers) and 52% (range 24-62%) of these were discharged on day of surgery. 21% (CI 20-23) of all patients (eligible and non-eligible) were discharged on day of surgery with a range of 10-31% within centers. This was an additional 15% (CI 13-17, P < 0.001) compared with patients discharged in the control period (6% in 2019). CONCLUSION We found it possible to perform outpatient hip and knee replacement in 21% of patients in a public healthcare setting, probably to be increased with further center experience.
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Affiliation(s)
- Oddrún Danielsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Svendborg.
| | - Claus Varnum
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle
| | - Christian Bredgaard Jensen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Hvidovre University Hospital
| | - Thomas Jakobsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Aalborg University Hospital
| | - Mikkel Rathsach Andersen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Copenhagen University Hospital, Herlev-Gentofte
| | | | - Søren Overgaard
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg
| | - Christoffer Calov Jørgensen
- Center for Fast-track Hip and Knee Replacement; Department of Anaesthesia, Hospital of Northern Zealand, Hillerød
| | - Henrik Kehlet
- Center for Fast-track Hip and Knee Replacement; Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kirill Gromov
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Hvidovre University Hospital
| | - Martin Lindberg-Larsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Svendborg
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Macheras GA, Tzefronis D, Argyrou C, Nikolakopoulou E, Gálvez Miravete A, Karachalios TS. Pain management after total hip arthroplasty: comparative study of analgesic efficacy and tolerability between oral tramadol/dexketoprofen and injectable paracetamol + tramadol. Hip Int 2024; 34:304-310. [PMID: 38204364 DOI: 10.1177/11207000231219797] [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] [Indexed: 01/12/2024]
Abstract
BACKGROUND Multimodal analgesia for total hip arthroplasty (THA) is increasingly employed to reduce early postoperative pain and promote fast patient discharge. The aim of this study was to compare the efficacy and tolerability of tramadol/dexketoprofen (TRAM/DKP, Group A) versus paracetamol + tramadol (PARA+TRAM, Group B) in patients undergoing THA using minimally invasive direct anterior approach (DAA). METHODS A single-centre, randomised, single-blind, parallel, interventional study conducted in 323 patients undergoing primary THA with DAA was performed. Group A consisted of 188 patients and Group B of 135. The primary endpoints were the change from baseline (measured 2 hours postoperatively) in pain intensity (PI) during the treatment period (48 hours), assessed by visual analogue scale (VAS) at pre-specified postoperative time-points (2, 8, 24, 48 hours) and the total rescue medication (RM) use during the first 24 hours postoperatively. RESULTS As early as 2 hours after baseline, Group A showed a greater PI reduction from baseline compared to Group B (-26.24% vs. -6.87%; p < 0.001). A lower mean PI (VAS) score was consistently found over the entire observation period following treatment with TRAM/DKP than with PARA+TRAM as well as more than 2-fold higher proportion of responders at the end of treatment period. More patients in Group B required RM in comparison to those in Group A (15.6% vs. 3.7%, p < 0.001). Both treatments were well tolerated. CONCLUSIONS After THA, oral TRAM/DKP provides faster and greater pain relief when compared to intravenous PARA+TRAM with limited consumption of RM and favourable tolerability profile. Our study expands the use of TRAM/DKP in the setting of major orthopaedic surgeries. CLINICAL TRIAL REGISTRATION clinicaltrials.gov (NCT04178109).
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MESH Headings
- Humans
- Pain, Postoperative/drug therapy
- Pain, Postoperative/diagnosis
- Arthroplasty, Replacement, Hip
- Male
- Female
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Middle Aged
- Ketoprofen/administration & dosage
- Ketoprofen/analogs & derivatives
- Ketoprofen/therapeutic use
- Single-Blind Method
- Aged
- Administration, Oral
- Pain Measurement
- Tromethamine/administration & dosage
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Treatment Outcome
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Drug Therapy, Combination
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Adult
- Pain Management/methods
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Affiliation(s)
- George A Macheras
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Dimitrios Tzefronis
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Chrysoula Argyrou
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Athens, Attica, Greece
| | - Elena Nikolakopoulou
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | | | - Thefilos S Karachalios
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University General Hospital of Larissa, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Thessalia Sterea Ellada, Greece
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8
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Barrett CC, Laperche J, Clippert D, Glasser J, Garcia D, Antoci V. The Immediate Impact of Total Knee Arthroplasty Removal From the Medicare Inpatient-Only List on Patient Derived Functional Outcomes and Hospital Satisfaction. J Arthroplasty 2024; 39:1253-1258. [PMID: 37952740 DOI: 10.1016/j.arth.2023.11.006] [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: 06/27/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is the standard of treatment for end-stage knee osteoarthritis. On January 1, 2018, the Centers for Medicare and Medicaid (CMS) officially removed TKA from their inpatient-only list. The clinical impact of this change is not fully understood yet. METHODS Electronic records were retrospectively reviewed for patients who underwent TKA between January 1 to June 30, 2017, or January 1 to June 30, 2018. Patients completed Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement surveys which assessed patient reported outcomes prior to and following TKA. Hospital statistics for the 2 time points were determined and compared. This was a single institution study resulting in 351 patients in the pre-CMS change group and 350 patients in the post-CMS change group. RESULTS Analysis of the pre-CMS and post-CMS transition cohorts indicated no significant difference in activities of daily living (ADLs), pain, or pain catastrophizing scale preoperatively or 12-months postoperatively. Additionally, there was no difference in the median change between preoperative and postoperative ADL scores (P = .866), yet pain scores approached significance with a P value of .054. The pre-CMS transition group stayed significantly longer in the hospital postoperatively and was more commonly discharged to a skilled nursing facility. No difference was seen in 30-day readmission rates (P = .253). CONCLUSIONS Results showed that patients had similar scores for ADL, quality of life, pain, and pain catastrophizing 12-months following their TKA. Movement of TKA from the Medicare inpatient only list did not have an immediate negative impact for patient reported outcomes and 30-day readmissions at our institution in the 6-month transition period.
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Affiliation(s)
| | - Jacob Laperche
- University Orthopedics Inc, East Providence, Rhode Island; Frank H. Netter School of Medicine, Quinnipiac University
| | - Drew Clippert
- University Orthopedics Inc, East Providence, Rhode Island
| | | | - Dioscaris Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Valentin Antoci
- University Orthopedics Inc, East Providence, Rhode Island; Warren Alpert Medical School of Brown University, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University and Rhode Island Hospital, Providence, Rhode Island
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9
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Jennewine BR, Throckmorton TW, Pierce AS, Miller AH, Azar AT, Sharp CD, Azar FM, Bernholt DL, Brolin TJ. Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update. J Shoulder Elbow Surg 2024; 33:900-907. [PMID: 37625693 DOI: 10.1016/j.jse.2023.07.018] [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: 04/03/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew S Pierce
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew H Miller
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adrian T Azar
- College of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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10
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Ip VHY, Uppal V, Kwofie K, Shah U, Wong PBY. Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations. Can J Anaesth 2024:10.1007/s12630-024-02699-0. [PMID: 38504037 DOI: 10.1007/s12630-024-02699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.
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Affiliation(s)
- Vivian H Y Ip
- Department of Anesthesia, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ushma Shah
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
| | - Patrick B Y Wong
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 501 Smyth Rd, CCW 1401, Ottawa, ON, K1H 8L6, Canada.
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Jensen CB, Troelsen A, Foss NB, Nielsen CS, Lindberg-Larsen M, Gromov K. Half of all hip and knee arthroplasty patients may be potential day-case candidates: a nationwide register study of 166,730 procedures. Acta Orthop 2024; 95:147-151. [PMID: 38393295 PMCID: PMC10886217 DOI: 10.2340/17453674.2024.40075] [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: 12/06/2023] [Accepted: 01/19/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND PURPOSE The overall potential pool of day-case candidates on a national level in hip and knee arthroplasty is unknown. We aimed to estimate the proportion of hip and knee arthroplasty patients eligible for day-case surgery based on contemporary widely used criteria and determine whether there has been a change in the proportion of eligible patients over time and, secondarily, to investigate the proportion of eligible patients discharged on the day of surgery. METHODS Based on data from the Danish National Patient Register, we identified all patients undergoing primary unilateral hip or knee arthroplasty from January 2010 to March 2020. Using a modification of day-case eligibility criteria proposed by a national multicenter collaboration, we sorted patients into either day-case eligible or ineligible. A day-case procedure was defined as discharge on the day of surgery. RESULTS We included patients comprising a total of 166,730 primary total hip (THA), total knee (TKA), and unicompartmental knee arthroplasty (UKA). 48% (95% confidence interval [CI] 48-49) were eligible for day-case surgery, with a decline from 50% (CI 49-51) in 2010 to 46% (CI 46-47) eligible in 2019. More UKA patients were day-case eligible (55%, CI 54-56) than THA (47%, CI 47-48) and TKA patients (49%, CI 48-49). A maximum of 8.0% (CI 7.4-8.5) of eligible patients were discharged on the day of surgery in 2019. CONCLUSION 48% of the Danish hip and knee arthroplasty patients were potential day-case candidates, with a small decline in eligibility from 50% in 2010 to 46% in 2019. Day of surgery discharge among day-case eligible patients peaked at 8% in 2019. Thus, the potential for more day-case surgery seems large.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre.
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
| | - Nicolai Bang Foss
- Department of Anesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre
| | - Christian Skovgaard Nielsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery, Orthopaedic Research Unit (ORU), Odense University Hospital, Odense, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
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12
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Lutz RW, Ponzio DY, Thalody HS, Patrizio HA, Czymek MM, Ast M, Post ZD, Ong AC. Social Risk Determinants for Successful Same Calendar Day Discharge in Total Joint Arthroplasty. HSS J 2024; 20:90-95. [PMID: 38356755 PMCID: PMC10863599 DOI: 10.1177/15563316231204231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 02/16/2024]
Abstract
Background While many studies have examined the impact of comorbidities on the success of same calendar day discharge (SCDD) in total joint arthroplasty (TJA), literature surrounding the impact of social determinants is lacking. Purpose We sought to investigate the relationship between various social determinants and success of SCDD after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods We conducted a retrospective review of 1160 THA and 1813 TKA performed at a single academic institution between November 2020 and August 2022. Social factors including substance use, occupation, marital status, income, and participation in physical exercise were included. In addition, aspects of discharge planning were reviewed such as living situation and transportation details. Results Overall, 952 (32%) patients had successful SCDD, whereas 2021 (68%) patients were discharged on postoperative day 1 (POD1) or greater. Successful SCDD patients were more likely to have health care (4.8% vs 2.5%) and active (5.4% vs 4.6%) rather than sedentary occupations, be married (79.6% vs 67.4%), have access to transportation (95.6% vs 92.9%), live in a higher median income area ($64,044 [16,183] vs $61,572 [14,594]), and exercise weekly (62.6% vs 23.9%). Interestingly, the successful patients had more stories in their homes (1.62 [0.56] vs 1.43 [0.53]), more stairs to enter their homes (5.19 [5.22] vs 4.60 [5.24]), lived farther from the hospital (43.3 [138.0] vs 32.0 [75.9] miles), and a higher prevalence of alcohol use (60.7% vs 44.7%) and tobacco use (19.3% vs 17.3%). Conclusion These findings may help arthroplasty surgeons to better understand the social factors that contribute to successful SCDD in TJA patients, ultimately aiding in patient selection and preoperative counseling.
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Affiliation(s)
- Rex W Lutz
- Jefferson Health New Jersey, Stratford, NJ, USA
| | | | - Hope S Thalody
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | | | - Miranda M Czymek
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Michael Ast
- Hospital for Special Surgery, New York City, NY, USA
| | - Zachary D Post
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Alvin C Ong
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
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13
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Radtke LE, Blackburn BE, Kapron CR, Erickson JA, Meier AW, Anderson LA, Gililland JM, Archibeck MJ, Pelt CE. Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch. J Arthroplasty 2024:S0883-5403(24)00028-7. [PMID: 38246314 DOI: 10.1016/j.arth.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.
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Affiliation(s)
- Logan E Radtke
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Claire R Kapron
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jill A Erickson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Adam W Meier
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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14
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Jensen CB, Gromov K, Foss NB, Kehlet H, Pleckaitiene L, Varnum C, Troelsen A. Spinal anaesthesia versus general anaesthesia (SAGA) on recovery after hip and knee arthroplasty: A study protocol for three randomized, single-blinded, multi-centre, clinical trials. Acta Anaesthesiol Scand 2024; 68:137-143. [PMID: 37743099 DOI: 10.1111/aas.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post-operative recovery between spinal anaesthesia and general anaesthesia; however, up-to-date comparisons in fast-track setups are needed. Our randomized, single-blinded, multi-centre, clinical trials aim to compare the post-operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast-track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0-2.0 mg/kg iv with Remifentanil 3-5 mcg/kg iv. Infusion: Propofol 3-5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast-track setup with intraoperative local infiltrative analgesia in TKA and UKA, post-operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in-hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5-m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post-operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30-days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast-track arthroplasty surgery.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lina Pleckaitiene
- Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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15
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Daher M, Haykal G, Ghoul A, Tarchichi J, Sebaaly A. The Efficacy of Bone Wax in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:298-305. [PMID: 38817421 PMCID: PMC11134256 DOI: 10.22038/abjs.2024.73243.3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/10/2024] [Indexed: 06/01/2024]
Abstract
Objectives This meta-analysis was conducted to study the hemostatic efficacy of bone wax in total joint arthroplasty (TJA) defined in this manuscript as total knee arthroplasty and total hip arthroplasty. Methods PubMed, Embase, Google Scholar (page 1-20), and Scopus were searched updated to November 2023. Only comparative studies were included. The clinical outcomes evaluated were the transfusion rate, total blood loss, and the loss of hemoglobin on day 1, 3, and 5 post-operatively. Results Only 3 studies met the inclusion criteria and were included in this meta-analysis. Bone wax was associated with a reduced transfusion rate (p=0.01), reduced total blood loss (p=0.001), and a decrease in hemoglobin loss on day 1 (p<0.00001), day 3 (p<0.0001), and day 5 (p<0.00001) after the surgery. Conclusion Bone wax reduced the rate of transfusion, total blood loss, and hemoglobin loss after the surgery. This may induce a reduction the cost of correcting post-operative anemia as well as decrease hospital stay and improving functional outcomes in patients undergoing TJA. Better-conducted randomized controlled studies and cost-effectivity studies could strengthen these findings.
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Affiliation(s)
- Mohammad Daher
- Saint Joseph University, Faculty of medicine, Beirut, Lebanon
| | - Gaby Haykal
- Saint Joseph University, Faculty of medicine, Beirut, Lebanon
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Ali Ghoul
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Jean Tarchichi
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Amer Sebaaly
- Saint Joseph University, Faculty of medicine, Beirut, Lebanon
- Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon
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White PB, Forte SA, Bartlett LE, Osowa T, Bondy J, Aprigliano C, Danoff JR. A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital. J Arthroplasty 2023; 38:2549-2555. [PMID: 37276952 DOI: 10.1016/j.arth.2023.05.065] [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: 03/12/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital. METHODS A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours. RESULTS We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%. CONCLUSION In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.
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Affiliation(s)
- Peter B White
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Salvador A Forte
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Lucas E Bartlett
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Temisan Osowa
- Donald and Barbara Zucker School of Medicine/Hofstra, Hempstead, New York
| | - Jed Bondy
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Caroline Aprigliano
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
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Lee MJ, Tucker CA, Fisher SR, Tahashilder MI, Prichard KT, Kuo YF. Increase in the Initial Outpatient Rehabilitation Utilization for Patients With Total Knee Arthroplasty. Arch Phys Med Rehabil 2023; 104:1812-1819.e6. [PMID: 37119952 DOI: 10.1016/j.apmr.2023.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES The objective of this study was to examine the patient characteristics and features associated with the initial rehabilitation utilization with a particular emphasis on outpatient rehabilitation after total knee arthroplasty (TKA) among 2016-2018 Texas Medicare enrollees. DESIGN This is a retrospective cohort study. We used chi-square tests to examine the variability in patient demographic and clinical characteristics across the different post-acute rehabilitation settings after TKA. A Cochran-Armitage trend test was used to investigate the yearly trend of outpatient rehabilitation utilization after TKA. SETTING Post-acute rehabilitation settings after TKA. PARTICIPANTS The target population was Medicare beneficiaries aged ≥65 with an initial TKA in 2016-2018 and complete demographic and residential information (N=44,313). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We identified whether patients first used (1) outpatient rehabilitation, (2) home health, (3) self-care, (4) inpatient rehabilitation, (5) skilled nursing, or (6) other setting within the 3 months after TKA. RESULTS Our results demonstrated an increasing use of the initial outpatient rehabilitation and home health, while the use of skilled nursing and inpatient rehabilitation facilities decreased from 2016 to 2018. The increase in outpatient utilization was significant in 2018 compared with 2016 controlling for distance to the TKA facilities, comorbid conditions, sex, race/ethnicity groups (White, Black, Hispanic, and Others), lower income (Medicaid eligible), Medicare entitlement types, age groups, and rurality (OR 1.23, 95% CI 1.12-1.34). However, the overall utilization rate of the initial outpatient rehabilitation after TKA remained low, increasing from 7.36% in 2016 to 8.60% in 2018. CONCLUSION Despite the growing use of the initial outpatient rehabilitation after TKA, the overall rate of outpatient rehabilitation utilization remained low. Our findings raise an important question as to whether certain patient demographics and clinical groups might have limited access to outpatient rehabilitation after TKA.
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Affiliation(s)
- Mi Jung Lee
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX.
| | - Carole A Tucker
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX; Center for Recovery, Physical Activity & Nutrition, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Steve R Fisher
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Kevin T Prichard
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Yong-Fang Kuo
- Office of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, TX; Department of Biostatistics and Data Science, University of Texas Medical Branch at Galveston, Galveston, TX
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18
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Gromov K, Price A, Mohaddes M, Della Valle C. Outpatient hip and knee arthroplasty: how is it utilized? Acta Orthop 2023; 94:511-513. [PMID: 37830939 PMCID: PMC10573362 DOI: 10.2340/17453674.2023.21318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/01/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Kirill Gromov
- Department of Orthopedic Surgery, Clinical Orthopaedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Copenhagen, Denmark.
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Maziar Mohaddes
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Craig Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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19
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Jensen CB, Troelsen A, Foss NB, Nielsen CS, Lindberg-Larsen M, Gromov K. No difference in short-term readmissions following day-case vs. one overnight stay in patients having hip and knee arthroplasty: a nationwide register study of 51,042 procedures from 2010-2020. Acta Orthop 2023; 94:516-522. [PMID: 37831058 PMCID: PMC10574241 DOI: 10.2340/17453674.2023.18658] [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: 05/01/2023] [Accepted: 09/02/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Day-case hip and knee arthroplasty has gained in popularity, but there are conflicting results regarding readmissions. We aimed to investigate differences in 30- and 90-day readmission rates between day-case patients and patients with a single overnight stay following primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). PATIENTS AND METHODS We identified day-case (DC) and overnight (ON) THA, TKA, and UKA patients, operated on between 2010 and 2020, from the Danish National Patient Register. Day-case surgery was defined as discharge on the day of surgery. Overnight readmissions within 30 or 90 days of surgery were considered readmissions. We compared readmission rates between DC and ON patients within arthroplasty types using logistic regression adjusted for patient characteristics and year of surgery. We included 29,486 THAs (1,353 DC and 28,133 ON), 15,116 TKAs (617 DC and 14,499 ON), and 6,440 UKAs (1,528 DC and 4,914 ON). RESULTS The 30-day readmission rates were: DC-THA 4.4% vs. ON-THA 4.4% (adjusted odds-ratio [aOR] 1.2, 95% confidence interval [CI] 0.91-1.6), DC-TKA 4.7% vs. ON-TKA 4.4% (aOR 1.1, CI 0.69-1.5), and DC-UKA 3.0% vs. ON-UKA 3.0% (aOR 1.1, CI 0.78-1.5). Similarly, no significant differences were present between DC and ON THA, TKA, and UKA regarding 90-day readmissions or time to readmission. CONCLUSION We found no differences in readmission rates between day-case THA, TKA, and UKA patients and patients with a single overnight stay.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre.
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
| | - Nicolai Bang Foss
- Department of Anesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre
| | - Christian Skovgaard Nielsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery, Orthopaedic Research Unit (ORU), Odense University Hospital, Odense, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre
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Moisander AM, Pamilo K, Eskelinen A, Huopio J, Kautiainen H, Kuitunen A, Paloneva J. Venous thromboembolism is rare after total hip and knee joint arthroplasty with long thromboprophylaxis in Finnish fast-track hospitals. Arch Orthop Trauma Surg 2023; 143:5623-5629. [PMID: 37067559 PMCID: PMC10449718 DOI: 10.1007/s00402-023-04842-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/01/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Pharmacological thromboprophylaxis effectively prevents venous thromboembolism (VTE) after total knee (TKA) and total hip arthroplasty (THA). Less is known about the influence of fast-track arthroplasty on VTE risk. We conducted a register-based study to determine the incidence of VTE after fast-track TKA and THA in Finland using long thromboprophylaxis. MATERIALS AND METHODS All primary TKAs and THAs operated during 2015-2016 in 3 fast-track hospitals were identified from the Finnish Arthroplasty Register. Pulmonary embolism (PE) and deep vein thrombosis (DVT) diagnosed in this patient cohort within 90 days of surgery were identified from the Finnish Hospital Discharge Register. The recommended length of thromboprophylaxis was 10 to 14 days for TKA and 28 days for THA during study period. RESULTS During the study period, 3 831 THAs, 4 394 TKAs and 286 bilateral TKAs (BTKAs) were performed. Of all these patients, 60% were females. Venous thromboembolism (VTE) incidence within 90 days of surgery was 0.3% (95% CI 0.2-0.4). These VTEs comprised 10 PEs and 15 DVTs. None of the VTE patients´ died within the 90-day period. CONCLUSION VTE incidence is low in Finnish fast-track TKA and THA patients with long thromboprophylaxis.
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Affiliation(s)
- Annette M Moisander
- Department of Anesthesia and Intensive Care, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland.
| | - Konsta Pamilo
- Coxa Hospital for Joint Replacement, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Jukka Huopio
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Wellbeing Servicies County of North Savo, Kuopio, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University, Folkhälsan Research Center, Helsinki, Finland
| | - Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Juha Paloneva
- Department of Surgery, Hospital Nova, Wellbeing Secvices County of Central Finland, Jyväskylä, Finland
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21
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Lindberg-Larsen M, Varnum C, Jakobsen T, Andersen MR, Sperling K, Overgaard S, Hansen TB, Jørgensen CC, Kehlet H, Gromov K. Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement. Acta Orthop 2023; 94:121-127. [PMID: 36942664 PMCID: PMC10028556 DOI: 10.2340/17453674.2023.11636] [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: 11/25/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers. PATIENTS AND METHODS This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.
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Affiliation(s)
- Martin Lindberg-Larsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and traumatology, Odense University Hospital and Svendborg.
| | - Claus Varnum
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Lillebaelt Hospital-Vejle
| | - Thomas Jakobsen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Aalborg University Hospital
| | - Mikkel Rathsach Andersen
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Copenhagen University Hospital, Herlev-Gentofte
| | - Kim Sperling
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Næstved, Slagelse and Ringsted Hospitals
| | - Søren Overgaard
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg
| | - Torben Bæk Hansen
- Center for Fast-track Hip and Knee Replacement; University Clinic for Hand, Hip and Knee Surgery, Hospital Unit West Jutland and Aarhus University
| | - Christoffer Calov Jørgensen
- Center for Fast-track Hip and Knee Replacement; Department of Anaesthesia, Hospital of Northern Zeeland, Hillerød
| | - Henrik Kehlet
- Center for Fast-track Hip and Knee Replacement; Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet
| | - Kirill Gromov
- Center for Fast-track Hip and Knee Replacement; Department of Orthopaedic Surgery, Hvidovre University Hospital, Denmark
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22
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Days Alive and Out of Hospital at 15 Days after Hip Replacement May Be Associated with Long-Term Mortality: Observational Cohort Study. Diagnostics (Basel) 2023; 13:diagnostics13061155. [PMID: 36980462 PMCID: PMC10047336 DOI: 10.3390/diagnostics13061155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
We aimed to evaluate the association between days alive and out of hospital (DAOH) and mortality at 15 days after a hip replacement. From March 2010 to June 2020, we identified 5369 consecutive adult patients undergoing hip replacements and estimated DAOH at 15, 30, 60, and 90 days after surgery. After excluding 13 patients who died within 15 days after surgery, receiver operating characteristic (ROC) curves were then generated to evaluate predictabilities for each follow-up period. We compared the mortality risk according to the estimated thresholds of DAOH at 15 days after hip replacement. ROC analysis revealed areas under the curve of 0.862, 0.877, 0.906, and 0.922 for DAOH at 15, 30, 60, and 90 days after surgery, respectively. The estimated threshold of DAOH during the 15 postoperative days was 6.5. Patients were divided according to this threshold, and propensity score matching was conducted. In a propensity score-matched population with 864 patients in each group, the risk of mortality increased in patients with a lower DAOH 15 (2.8% vs. 8.1%; hazard ratio [HR] = 3.96; 95% confidence interval [CI]: 2.24–6.99; p < 0.001 for one-year mortality, 5.2% vs. 13.0%; HR = 3.82; 95% CI: 2.33–6.28; p < 0.001 for three-year mortality, and 5.9% vs. 15.6%; HR = 3.07; 95% CI: 2.04–4.61; p < 0.001 for five-year mortality). In patients undergoing a hip replacement, DAOH at 15 days after surgery was shown to be associated with increased mortality. DAOH at 15 days may be used as a valid outcome measure for hip replacement.
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23
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Gao NP, Al-Dadah O. Comparison of day-case versus inpatient uni-compartmental knee replacement. Musculoskeletal Care 2023; 21:16-24. [PMID: 35652292 DOI: 10.1002/msc.1662] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Uni-compartmental knee replacement (UKR) is an alternative to total knee replacement for patients who have isolated compartment osteoarthritis. Studies have demonstrated that UKR can be safely performed as a day-case procedure without a negative impact on complication rates. The aim of this study was to compare the clinical outcomes between day-case and inpatient UKRs. METHODS A single surgeon prospective case-controlled study was performed, comparing data between day-case UKRs and inpatient UKRs. This included longitudinal analysis of patient reported outcome measures (PROMs); including the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Short Form 12-item Health Survey, EQ-5D-5L and the Self-administered Comorbidity Questionnaire. Post-operative pain scores (visual analogue scale), unplanned post-operative hospital reattendance rates and complications were also analysed. RESULTS Overall, 100% of day-case patients were successfully discharged on the same day. Both inpatient (n = 23) and day-case (n = 23) UKRs demonstrated a significant within group longitudinal improvement of PROM scores (p < 0.05) following surgery. However, the post-operative PROM scores were significantly higher in the day-case group as compared to the inpatient group (p < 0.05). Both groups had comparable post-operative pain scores, but the day-case group demonstrated fewer unplanned reattendances and post-operative complications. CONCLUSION The clinical outcomes of day-case UKR are superior to inpatient UKR. Careful patient selection and a robust multidisciplinary patient pathway are the key components to success of day-case joint replacement surgery. LEVEL OF EVIDENCE Prospective Case-Control Study, level III.
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Affiliation(s)
- Neng-Ping Gao
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside, UK
| | - Oday Al-Dadah
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside, UK.,Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
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24
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Cozzarelli NF, Longenecker AS, Uhr A, Davis DE, Lonner JH. Unicompartmental Knee Arthroplasty Is Cost-Effective in an Outpatient Setting. Cureus 2023; 15:e35059. [PMID: 36942167 PMCID: PMC10024511 DOI: 10.7759/cureus.35059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
INTRODUCTION Increasingly, unicompartmental knee arthroplasty (UKA) is being performed on an outpatient basis, with the growing utilization of ambulatory surgery centers (ASCs). The purpose of this study was to compare the costs of UKAs performed in an ASC to UKAs done in a hospital, either on an outpatient or inpatient basis. METHODS This study involved three matched groups, each with 50 consecutive patients, undergoing UKA either on an outpatient basis in an ASC or a community hospital, or who were admitted overnight to the same community hospital. Identical perioperative analgesic regimens and care protocols were used in each group. The primary outcomes evaluated included direct facility costs. Secondary outcomes were postoperative complications and readmissions. RESULTS Average age, gender ratio, and comorbidities were similar in all three cohorts. Only two patients in the study experienced complications and these were without secondary adverse consequences. Mean costs were substantially reduced when UKAs were performed in an ASC ($9,025) compared to a community hospital on either an outpatient ($12,032) or inpatient basis ($14,542). CONCLUSION UKA can be safely performed in the outpatient setting, in appropriately selected patients, at substantial cost savings, particularly when performed in an ASC.
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Affiliation(s)
- Nicholas F Cozzarelli
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA
| | - Andrew S Longenecker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA
| | - Alex Uhr
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA
| | - Daniel E Davis
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA
| | - Jess H Lonner
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA
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25
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Manevskiу AA, Sviridov SV, Melekhov AV, Barmotin GV, Demin AK, Nikitin IG. Enhanced Recovery in Total Knee and Hip Arthroplasty: the Need for National Recommendations. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-6-86-96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- A. A. Manevskiу
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
| | | | - A. V. Melekhov
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
| | - G. V. Barmotin
- National Medical Research Center, Medical and Rehabilitation Center
| | - A. K. Demin
- National Medical Research Center, Medical and Rehabilitation Center; Institute for Leadership and Health Management, I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. G. Nikitin
- National Medical Research Center, Medical and Rehabilitation Center; Pirogov Russian National Research Medical University
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26
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Hammerberg EM, Tucker NJ, Stacey SC, Mauffrey C, Heare A, Verduzco LA, Parry JA. Institution of same-day total joint replacement at an urban safety net hospital during the COVID-19 pandemic. J Orthop 2022; 34:173-177. [PMID: 36060728 PMCID: PMC9422337 DOI: 10.1016/j.jor.2022.08.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/15/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background Increasingly, total hip and total knee replacements are being performed at outpatient ambulatory surgery centers. The purpose of this study was to investigate the feasibility and safety of instituting a same-day surgery program for hip and knee replacement at an urban, safety net hospital. Methods Retrospective review of a prospectively collected registry for all patients scheduled for same-day total joint replacement at a safety net hospital was performed. Medical records were reviewed for patient demographics, same-day hospital admissions, and 30-day emergency room/hospital admissions. Results 131 same-day total joint replacements were identified, including 76 knees and 55 hips. Median ASA was 3, and median Charlson comorbidity score was 2. Rate of same-day surgery for total joint replacements increased from 4.5% in September 2020 to 100% in September 2021. On major patient outcomes, 3.8% of patients (n = 5) required conversion to inpatient admission. Rate of 30-Day Emergency Department (ED) visits was 13.0% (n = 17). Most common complaints included postoperative pain (n = 10), incision drainage/edema/hematoma (n = 9), and cellulitis (n = 2). 30-Day Hospital Readmissions occurred in 1.5% of patients (n = 2). Conclusion Same-day hip and knee replacement can be performed safely at a safety net hospital. Unlike dedicated high-volume orthopedic hospitals or outpatient surgery centers, urban safety net hospitals face a different set of challenges and must care for a wide variety of patients who do not plan for their illness and/or may not be able to pay for their care. Outpatient total joint replacement may extend total joint replacement to patients who might not have access otherwise.
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Affiliation(s)
- E. Mark Hammerberg
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
- Corresponding author. Denver Health Medical Center, Department of Orthopedic Surgery , 777 Bannock St, Denver, CO 80204, USA
| | - Nicholas J. Tucker
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
| | - Stephen C. Stacey
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
| | - Cyril Mauffrey
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
| | - Austin Heare
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
| | - Luis A. Verduzco
- Denver Health Medical Center, Department of Anesthesiology, USA
- University of Colorado School of Medicine, Department of Anesthesiology, USA
| | - Joshua A. Parry
- Denver Health Medical Center, Department of Orthopedic Surgery, 777 Bannock St, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Orthopedics, CU Anschutz Academic Office One, 12631 East 17th Avenue, #4602, Aurora, CO, 80045, USA
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Mortazavi SMJ, Razzaghof M, Ghadimi E, Seyedtabaei SMM, Vahedian Ardakani M, Moharrami A. The Efficacy of Bone Wax in Reduction of Perioperative Blood Loss in Total Hip Arthroplasty via Direct Anterior Approach: A Prospective Randomized Clinical Trial. J Bone Joint Surg Am 2022; 104:1805-1813. [PMID: 35984033 DOI: 10.2106/jbjs.22.00376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Perioperative blood management in total hip arthroplasty (THA) has become a prime focus of research. Given the morbidity, delayed recovery, and prolonged hospital stay associated with postoperative anemia, various measures have been proposed to reduce perioperative blood loss (PBL). In this trial, we studied the efficacy of bone wax application on the distal cut surface of the femoral neck in reducing PBL during THA through the direct anterior approach. METHODS In a randomized controlled clinical trial, 152 patients underwent THA through the direct anterior approach with use of bone wax (n = 75) or without bone wax (control) (n = 77). The study was triple-blinded. The primary outcomes were apparent PBL (blood in sponges and suction canister) and total PBL on postoperative days (PODs) 3 and 5 (as calculated with the Good and Nadler methods). Transfusion and complications were the secondary outcomes. RESULTS No significant difference was found between the 2 groups in terms of age, sex, body mass index, American Society of Anesthesiologists score, etiology, preoperative hematologic/coagulation profile, anesthesia, intraoperative mean arterial pressure, or operative time. Apparent PBL, total PBL on POD3, and total PBL, in milliliters, on POD5 were significantly lower in the wax group, with median values of 200 (interquartile range [IQR]: 115 to 310) versus 370 (IQR: 195 to 513.7), 505.2 (IQR: 409.2 to 637.6) versus 747 (IQR: 494.6 to 955.4), and 536.7 (IQR: 430.9 to 689.3) versus 767.8 (IQR: 537.8 to 1,021.9) in the wax and control groups, respectively (p < 0.001). No significant differences in the rates of transfusion and complications were found. CONCLUSIONS Bone wax on the cut surface of femoral neck can significantly reduce PBL during THA through the direct anterior approach. Bone wax is accessible and inexpensive and can be considered a routine part of the surgical technique in THA through the direct anterior approach. This intervention has no impact on complication or transfusion rates. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Vahedian Ardakani
- Department of Orthopedic Surgery, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Moharrami
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
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28
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Improved clinical outcomes of outpatient enhanced recovery hip and knee replacements in comparison to standard inpatient procedures: A study of patients who experienced both. Orthop Traumatol Surg Res 2022; 108:103236. [PMID: 35150928 DOI: 10.1016/j.otsr.2022.103236] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/02/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. This study's main objective was to evaluate adverse events with an ERAS-outpatient compared to standard-inpatient care and secondary objectives were to compare pain, functional recovery, PROMs and satisfaction. HYPOTHESIS The ERAS-outpatient program would result in reduced adverse events compared to standard-inpatient care. METHODS An ambidirectional single subject cohort study was conducted on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). Adverse event rate according to the Clavien-Dindo scale, the Comprehensive Complications Index (CCI) and the number of unplanned episodes of care were assessed. Postoperative pain on a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient reported outcome measures (PROMs) (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs. 4.4, p<0.001), CCI was significantly lower (12.3 vs. 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs. 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p>0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p<0.002). CONCLUSION Compared to the conventional inpatient care, the ERAS-outpatient program proved to be safer, enable faster functional recovery, and improve patients' satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program. LEVEL OF EVIDENCE III; Ambidirectional Cohort study.
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29
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Berardino K, Carroll AH, Ricotti R, Popovsky D, Civilette MD, Urits I, Viswanath O, Sherman WF, Kaye AD. The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties. Orthop Rev (Pavia) 2022; 14:37496. [PMID: 36045694 DOI: 10.52965/001c.37496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.
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Affiliation(s)
| | | | | | | | | | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport
| | - Omar Viswanath
- Innovative Pain and Wellness; Department of Anesthesiology, Creighton University School of Medicine
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center Shreveport
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30
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Rodriguez S, Shen TS, Lebrun DG, Della Valle AG, Ast MP, Rodriguez JA. Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors. Bone Jt Open 2022; 3:684-691. [PMID: 36047458 PMCID: PMC9533240 DOI: 10.1302/2633-1462.39.bjo-2022-0106.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aims The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691.
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Affiliation(s)
- Samuel Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Tony S. Shen
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Drake G. Lebrun
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Alejandro G. Della Valle
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Michael P. Ast
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Jose A. Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
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Vandepitte C, Van Pachtenbeke L, Van Herreweghe I, Gupta RK, Elkassabany NM. Same Day Joint Replacement Surgery: Patient Selection and Perioperative Management. Anesthesiol Clin 2022; 40:537-545. [PMID: 36049880 DOI: 10.1016/j.anclin.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Joint replacements are increasingly performed as outpatient surgeries. The push toward ambulatory joint arthroplasty is driven in part by the changing current health care economics and reimbursement models. Patients' selection and well-designed perioperative care pathways are critical for the success of these procedures. The rate of complications after outpatient joint arthroplasty is comparable to the rate of complications in the ambulatory setting. Patient education, adequate social support, multimodal analgesia, regional anesthesia are key ingredients to the ambulatory care pathway after joint arthroplasty. Motor sparing nerve blocks are often used in these settings. Implementation of the elements of fast protocols can result in overall improvement of outcome metrics for all patients undergoing joint arthroplasty, including reduced length of stay and increased rate of home discharge.
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Affiliation(s)
- Catherine Vandepitte
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk 3600, Belgium
| | - Letitia Van Pachtenbeke
- Department of Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Schiepse Bos 6, Genk 3600, Belgium
| | - Imré Van Herreweghe
- Department of Anesthesiology, AZ Turnhout, Rubensstraat 166, 2300 Turnhout, Belgium
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive 4648, The Vanderbilt Clinic (TVC), Nashville, TN 37232-5614, USA. https://twitter.com/SportsDoc2009
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA.
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LeBrun DG, LaValva SM, Waddell BS, Mayman DJ, Jerabek SA, Alexiades MM, Ast MP. No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty. HSS J 2022; 18:338-343. [PMID: 35846259 PMCID: PMC9247591 DOI: 10.1177/15563316211055069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023]
Abstract
Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.
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Affiliation(s)
- Drake G. LeBrun
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA,Drake G. LeBrun, MD, MPH, Department of
Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for
Special Surgery, New York, NY 10021, USA.
| | - Scott M. LaValva
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Bradford S. Waddell
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - David J. Mayman
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Seth A. Jerabek
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Michael M. Alexiades
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Michael P. Ast
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
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Singh V, Realyvasquez J, Simcox T, Lajam CM, Schwarzkopf R, Davidovitch RI. A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study. J Arthroplasty 2022; 37:S823-S829. [PMID: 35219819 DOI: 10.1016/j.arth.2022.02.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/31/2022] [Accepted: 02/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ. CONCLUSION Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - John Realyvasquez
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Trevor Simcox
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Short-Stay Arthroplasty is Not Associated With Increased Risk of 90-Day Hospital Returns. J Arthroplasty 2022; 37:S819-S822. [PMID: 35093543 DOI: 10.1016/j.arth.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND With the removal of total hip arthroplasty (THA) and total knee arthroplasty (TKA) from the inpatient-only list, medical centers are faced with challenging transitions to outpatient surgery. We investigated if short-stay arthroplasty, defined as length of stay (LOS) <24 hours, would influence 90-day readmissions and emergency department (ED) visits at a tertiary referral center. METHODS The institutional database was retrospectively queried for primary TKAs and THAs from July 2015 to January 2018, resulting in 2,217 patients (1,361 TKA and 856 THA). Patient demographics, including age, gender, body mass index, and American Society of Anesthesiologists score were collected. LOS, disposition, cost of care, 90-day ED visits, and readmissions were identified through the institutional database using electronic medical record data. Univariable and multivariable models were used to evaluate rates of 90-day readmissions and ED visits based on LOS <24 hours vs ≥24 hours. RESULTS LOS <24 h was associated with significant decreases in 90-day ED visits (P = .003) and readmissions (P = .002). After controlling for potential confounding variables with a multivariable model, a significant decrease in ED visits (P = .034) remained in the THA cohort alone. Within TKA and THA cohorts, LOS <24 h was associated with lower costs (P < .001). Eighteen percent of patients with ≥24 h LOS were discharged to skilled nursing or rehabilitation facilities. CONCLUSION In this cohort, LOS <24 hours was associated with decreased 90-day readmissions, ED visits, and costs. With the goal of minimizing costs and maintaining patient safety while efficiently using resources, outpatient and short-stay arthroplasty are valuable, feasible options in tertiary academic centers.
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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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Jenny JY, Gisonni V. 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. Orthop Traumatol Surg Res 2022; 108:103206. [PMID: 35074536 DOI: 10.1016/j.otsr.2022.103206] [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: 11/02/2020] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Jean-Yves Jenny
- Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - Vincent Gisonni
- Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
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Elmoghazy AD, Lindner N, Tingart M, Salem KH. Conventional versus fast track rehabilitation after total hip replacement: A randomized controlled trial. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221076501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Total hip replacement (THR) is currently the most successful orthopaedic operation worldwide. This success is, however, dependent on the quality and efficiency of postoperative rehabilitation programs following it. Methods: In a randomized controlled trial (RCT), sixty patients (32 females, 28 males, mean age 68.4 years) undergoing THR for hip arthritis having either a conventional rehabilitation after a normal hospital stay (30 patients) or a fast track rehabilitation program (30 patients) were compared. Results: The mean length of stay in the conventional group was 7.8 (range: 6–11) days compared to 4.5 (range 3–5) days in the fast track group ( p = <0.001). Complications included one dislocation in either group, a case of heart failure and a readmission in the conventional group. As regards functional outcome, patients in the conventional group had a mean Harris Hip Score of 69.3 six weeks and 82 twelve weeks postoperatively in comparison to 79 and 91 in the fast track group respectively. The differences were statistically significant ( p = 0.013 and 0.002 respectively). Conclusion: Fast track rehabilitation after THR allows early patient's mobilization and shorter hospital stay with better functional outcome and without increasing the risk of complications or the readmission rate.
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Affiliation(s)
- Alyaa Diaa Elmoghazy
- Department of Orthopaedic Surgery, RWTH University Aachen, Aachen, Germany
- Department of Orthopaedic Surgery, Brüderkrankenhaus Paderborn, Paderborn, Germany
| | - Norbert Lindner
- Department of Orthopaedic Surgery, Brüderkrankenhaus Paderborn, Paderborn, Germany
| | - Markus Tingart
- Department of Orthopaedic Surgery, RWTH University Aachen, Aachen, Germany
| | - Khaled Hamed Salem
- Department of Orthopaedic Surgery, RWTH University Aachen, Aachen, Germany
- Department of Orthopaedic Surgery, Brüderkrankenhaus Paderborn, Paderborn, Germany
- Department of Orthopaedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
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Saunders P, Smith N, Syed F, Selvaraj T, Waite J, Young S. Introducing a day-case arthroplasty pathway significantly reduces overall length of stay. Bone Jt Open 2021; 2:900-908. [PMID: 34729998 PMCID: PMC8636294 DOI: 10.1302/2633-1462.211.bjo-2021-0106.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908.
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Affiliation(s)
- Paul Saunders
- Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Nick Smith
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Farhan Syed
- University Hospital Coventry & Warwickshire, Coventry, UK
| | - Thomas Selvaraj
- Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Jon Waite
- Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Stephen Young
- Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
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Reddy NC, Prentice HA, Paxton EW, Hinman AD, Lin AG, Navarro RA. Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3. J Bone Joint Surg Am 2021; 103:2032-2044. [PMID: 34495903 DOI: 10.2106/jbjs.20.02110] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Nithin C Reddy
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Abraham G Lin
- Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, California
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40
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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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41
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Baker P, Andrews SN, Mathews K, Nishioka S, Nakasone CK. Stepping toward outpatient total hip arthroplasty with a rapid discharge protocol. J Orthop 2021; 27:153-157. [PMID: 34650323 DOI: 10.1016/j.jor.2021.09.012] [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: 06/25/2021] [Revised: 07/26/2021] [Accepted: 09/26/2021] [Indexed: 11/20/2022] Open
Abstract
With total hip arthroplasty no longer an inpatient only procedure, this study retrospectively evaluated the percentage of same day, outpatient (<24 h) and inpatient (>24 h) discharges between 543 standard discharge (SDP) and 372 rapid discharge (RDP) patients. Outpatient discharges increased from 31.9% with SDP to 87.4% with RDP (p < 0.001) and 16.4% achieving same day discharge. Patients not achieving outpatient discharge were more commonly older (odds ratio (OR):1.052, p = 0.003), female (OR:2.715, p = 0.003) and a higher comorbidity classification (OR:2.751, p = 0.002). The 12.6% of patients failing to achieve outpatient discharge suggests that careful patient selection may be necessary to obtain 100% success.
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Affiliation(s)
- Paul Baker
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Samantha N Andrews
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
- University of Hawai'i, Department of Surgery, 1356 Lusitana Street, Honolulu, HI, 96813, USA
| | - Kristin Mathews
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Scott Nishioka
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Cass K Nakasone
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96813, USA
- University of Hawai'i, Department of Surgery, 1356 Lusitana Street, Honolulu, HI, 96813, USA
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Lovasz G, Aros A, Toth F, Va Faye J, La Malfa M. Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties. J Orthop Surg Res 2021; 16:585. [PMID: 34635122 PMCID: PMC8504781 DOI: 10.1186/s13018-021-02737-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward. METHODS 200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period. RESULTS 166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%. CONCLUSION Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.
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Affiliation(s)
- Gyorgy Lovasz
- Practice Plus Group Hospital Barlborough, 2 Lindrick Way, Barlborough, S43 4XE, Chesterfield, UK.
| | - Attila Aros
- Practice Plus Group Hospital Barlborough, 2 Lindrick Way, Barlborough, S43 4XE, Chesterfield, UK
| | - Ferenc Toth
- Practice Plus Group Hospital Barlborough, 2 Lindrick Way, Barlborough, S43 4XE, Chesterfield, UK
| | - John Va Faye
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Marco La Malfa
- Practice Plus Group Hospital Barlborough, 2 Lindrick Way, Barlborough, S43 4XE, Chesterfield, UK
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43
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Husted CE, Husted H, Nielsen CS, Mikkelsen M, Troelsen A, Gromov K. No increase in postoperative contacts with the healthcare system following outpatient total hip and knee arthroplasty. Acta Orthop 2021; 92:557-561. [PMID: 33977859 PMCID: PMC8519514 DOI: 10.1080/17453674.2021.1922966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Discharge on the day of surgery (DDOS) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) has been shown to be safe in selected patients. Concerns have been raised that discharging patients on the day of surgery (DOS) could lead to an increased burden on other parts of the healthcare system when compared with patients not discharged on the DOS (nDDOS). Therefore, we investigated whether discharging patients on the day of surgery (DOS) after THA and TKA leads to increased contacts with the primary care sector or other departments within the secondary care sector.Patients and methods - Prospective data on 261 consecutive patients scheduled for outpatient THA (n = 135) and TKA (n = 126) were collected as part of a previous cohort study. 33% of THA patients and 37% of TKA patients were discharged on the DOS. Readmissions within 3 months after surgery were recorded. Contacts with the discharging department, other departments, and primary care physicians within 3 weeks were registered.Results - No statistically significant differences were found when comparing DDOS patients and patients not discharged on the DOS (nDDOS) with regard to readmissions, physical contacts with the discharging department, and contacts with other departments as well as general practitioners. THA DDOS patients had significantly fewer contacts with the discharging department by telephone than THA nDDOS patients. TKA DDOS patients had significantly more contacts with the discharging department by telephone than TKA nDDOS patients.Interpretation - Patients discharged on the DOS following THA or TKA generally have similar postoperative contacts with the healthcare system when compared with patients not discharged on the DOS.
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Affiliation(s)
- Christian E Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark,Correspondence:
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | | | - Mette Mikkelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
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De Wouters S, Petronilia S, Paulet D, De Baere T, Willemart E, Cornu O. Outpatient total hip arthroplasty : the future? Acta Orthop Belg 2021. [DOI: 10.52628/87.2.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
With advancements in minimally invasive surgical technique, pain management and rehabilitation proto- cols, and prevention of post-operative complications, outpatient total hip arthroplasty became a realistic goal. This study reports our experience of performing outpatient total hip arthroplasty assessing its feasi- bility and safety.
Between December 2015 and January 2018, 52 outpatient total hip arthroplasties were performed. We implemented a peri-operative management proto- col that included education, improved analgesia and rapid rehabilitation. Patients were asked about any complications they had experienced after surgery and about the perception of their experience as outpatient. Any early post-operative emergency department visits, acute office appointments or hospital re-ad- missions were registered.
Fifty-one of 52 patients (98,1%) enrolled in the study met the discharge criteria and achieved their goal of going home on the day of surgery, and only one patient (1,9%) required an overnight stay. There were two visits to the emergency room, with one hospital re-admission (1,9%) on the night of the surgery. There were no major post-discharge complications in the short-term follow-up (minimum of three months). Only one patient (1,9%) reported a significantly negative experience.
With this first Belgian experience reporting on out- patient primary total hip arthroplasty, our data demonstrate that early discharge does not result in excessive re-admissions or other post-discharge complications due to an early discharge. This study suggests that total hip arthroplasty can be performed safely and successfully in appropriately selected patients and that patients who experienced that ambulatory protocol declared themselves highly satisfied.
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de Carvalho Almeida RF, Serra HO, de Oliveira LP. Fast-track versus conventional surgery in relation to time of hospital discharge following total hip arthroplasty: a single-center prospective study. J Orthop Surg Res 2021; 16:488. [PMID: 34384468 PMCID: PMC8359555 DOI: 10.1186/s13018-021-02640-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022] Open
Abstract
Background Total hip arthroplasty (THA) has been used for over five decades for treating hip osteoarthritis. THA is a surgical procedure associated with prolonged hospital length of stay (LOS). The aim of this study was to analyze whether a protocol developed for fast-track THA could decrease the time taken to reach functional recovery after surgery and the hospital LOS. Blood transfusion and critical care requirements and the complication rate were evaluated as secondary endpoints. Methods Ninety-eight patients underwent THA at the University Hospital of the Federal University of Maranhão (São Luís, Brazil). The control group included 51 patients who underwent THA through the conventional method. The fast-track surgery (FTS) group included 47 patients who underwent THA through the FTS approach. The inclusion criteria were that the subjects needed to present hip osteoarthritis and at least one clinical indication for THA, and that their risk classification was in ASA category I or II. The following factors were evaluated: age, sex, diagnosis, laterality, type of arthroplasty, blood transfusion, critical care requirement, complications, LOS, and need for re-hospitalization for any reason. For spinal anesthesia, an opioid-free protocol was used. Comparison of categorical variables between the groups was performed using the chi-square test, Shapiro-Wilk test, Student t test, and Poisson regression approach. Results The FTS and control groups were similar in age and sex distribution (p > 0.05). The majority of the patients in the control group required both blood transfusion and use of the critical care unit, thus differing from the patients who underwent FTS (p < 0.001). The mean hospital LOS in the FTS group was 2.3 ± 0.8 days, compared with 6.4 ± 1.5 days in the control group (p < 0.001). Conclusion Use of FTS was associated with decreased LOS, compared with conventional THA. Trial registration https://www.researchsquare.com/article/rs-369025/v1.
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Affiliation(s)
| | | | - Liszt Palmeira de Oliveira
- Department of Orthopedics, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
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Wang M, Xie J, Zheng H, Wang S, Zhou R, Li W, Xue E, Wang X, Jiang J, Wu T, Zhan S. Wound complications and bleeding with new oral anticoagulants in patients undergoing total joint arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2021; 88:500-513. [PMID: 34322914 DOI: 10.1111/bcp.15005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/18/2021] [Accepted: 07/15/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS The results of associations between new oral anticoagulants (NOACs) and wound complications after total joint arthroplasty remain inconsistent. We conducted a systematic review and meta-analysis of randomized controlled trials to make comparisons with low molecular weight heparins (LMWH) on the clinical outcomes of total wound complications, together with other efficacy and safety endpoints to further evaluate the safety and efficacy of NOACs. METHODS This meta-analysis was conducted based on a published protocol (PROSPERO: CRD42019140841). We searched for available articles in PubMed, Embase and Cochrane Library through Jun 62 021. Random-effects meta-analyses, including subgroup analyses, were conducted to estimate the pooled relative risk (RR) and 95% confidence interval (CI) for specific doses of NOACs. RESULTS We retrieved 1683 studies, of which 20 were eligible for inclusion. We found that apixaban was associated with a lower incidence of total wound complications compared with LMWH (RR = 0.81; 95% CI: 0.65-1.00), while dabigatran and rivaroxaban did not increase the risk of total wound complications. In addition, apixaban was associated with a reduction in the risk of major/clinically relevant nonmajor bleeding events compared to LMWH (RR = 0.80, 95% CI: 0.65-0.99), while rivaroxaban increased the risk for major/clinically relevant nonmajor bleeding events (RR = 1.23, 95% CI: 1.02-1.50). Moreover, all 4 NOACs were associated with lower incidences of major venous thromboembolism compared with LMWH. CONCLUSION A lower risk of wound complications was detected for apixaban, while dabigatran and rivaroxaban did not increase the risk when compared with LMWH. The efficacy of 4 NOACs was broadly similar.
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Affiliation(s)
- Mengying Wang
- School of Public Health, Peking University, Beijing, China
| | - Jinwei Xie
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Hongchen Zheng
- School of Public Health, Peking University, Beijing, China
| | - Siyue Wang
- School of Public Health, Peking University, Beijing, China
| | - Ren Zhou
- School of Public Health, Peking University, Beijing, China
| | - Wenyong Li
- School of Public Health, Peking University, Beijing, China
| | - Enci Xue
- School of Public Health, Peking University, Beijing, China
| | - Xueheng Wang
- School of Public Health, Peking University, Beijing, China
| | - Jin Jiang
- School of Public Health, Peking University, Beijing, China
| | - Tao Wu
- School of Public Health, Peking University, Beijing, China.,Institute of Reproductive and Child Health/Key Laboratory of Reproductive Health, National Health Commission of the People's Republic of China, China
| | - Siyan Zhan
- School of Public Health, Peking University, Beijing, China
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Zomar BO, Bryant DM, Hunter SW, Howard JL, Lanting BA. Perioperative gait analysis after total hip arthroplasty: Does outpatient surgery compromise patient outcomes? Can J Surg 2021; 64:E407-E413. [PMID: 34296768 PMCID: PMC8410462 DOI: 10.1503/cjs.008620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: There has been a continuing trend toward decreasing the length of hospital stay for patients undergoing total hip arthroplasty (THA). We aimed to investigate the impact of timing of discharge on gait and patient-reported outcomes early after THA. Methods: In this prospective observational cohort study conducted from May 2014 to November 2015, we measured gait velocity, stride length, single-limb support and single-limb support symmetry in adults aged 18−75 years before direct anterior THA, at discharge from the hospital, and 2, 6 and 12 weeks postoperatively. All procedures were performed by a single surgeon. Patients were discharged on the same day as surgery (outpatient group) or stayed at least 1 night in hospital (inpatient group). Participants also completed the Timed Up and Go test (all postoperative time points) and a series of questionnaires (Western Ontario and McMaster Universities Osteoarthritis Index [6 and 12 wk], 12-Item Short Form Health Survey [2, 6 and 12 wk], Harris Hip Score [12 wk] and a pain visual analogue scale [all postoperative time points]). Results: Thirty-six participants were enrolled in the study, of whom 16 were outpatients and 20 were inpatients. The mean pain rating at the time of discharge was lower in the outpatient group than in the inpatient group (adjusted mean difference −1.5, 95% confidence interval −3.0 to 0.0). We found no other significant differences between the groups for any gait, patient-reported or surgical outcome. Conclusion: There were no statistically significant differences in gait or patient-reported outcomes after direct anterior THA between patients who stayed overnight and those who were discharged as outpatients. Patients discharged as outpatients were younger than those who stayed overnight. Our results suggest that discharging patients as an outpatient after direct anterior THA may have a similar impact on patient function and outcomes as a standard overnight stay in hospital.
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Affiliation(s)
- Bryn O Zomar
- From the Faculty of Health Sciences, Western University, London, Ont. (Zomar, Bryant, Hunter); the Bone and Joint Institute, Western University, London, Ont. (Zomar, Bryant); the London Health Sciences Centre, London, Ont. (Howard, Lanting); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting)
| | - Dianne M Bryant
- From the Faculty of Health Sciences, Western University, London, Ont. (Zomar, Bryant, Hunter); the Bone and Joint Institute, Western University, London, Ont. (Zomar, Bryant); the London Health Sciences Centre, London, Ont. (Howard, Lanting); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting)
| | - Susan W Hunter
- From the Faculty of Health Sciences, Western University, London, Ont. (Zomar, Bryant, Hunter); the Bone and Joint Institute, Western University, London, Ont. (Zomar, Bryant); the London Health Sciences Centre, London, Ont. (Howard, Lanting); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting)
| | - James L Howard
- From the Faculty of Health Sciences, Western University, London, Ont. (Zomar, Bryant, Hunter); the Bone and Joint Institute, Western University, London, Ont. (Zomar, Bryant); the London Health Sciences Centre, London, Ont. (Howard, Lanting); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting)
| | - Brent A Lanting
- From the Faculty of Health Sciences, Western University, London, Ont. (Zomar, Bryant, Hunter); the Bone and Joint Institute, Western University, London, Ont. (Zomar, Bryant); the London Health Sciences Centre, London, Ont. (Howard, Lanting); and the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Howard, Lanting)
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Tomasi V, Demurie A, Ghijselings I, Cornu O, Van Den Wyngaert H. Influence of outpatient total knee arthroplasty compared to inpatient surgery on medical and economic outcomes. Acta Orthop Belg 2021. [DOI: 10.52628/87.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Firstly, this study compared the rate of readmission after a total knee arthroplasty between selected out- patients (no hospitalization, directly sent home after surgery) and inpatients (3 days hospitalization) at 6 weeks. Secondly, it examined the mobility and the complications in the two groups after the same period of time.
The rate of readmission, complications and knee mobility of 32 outpatients (M-age : 61 years ± 10 ; 10 females), were compared against those of 32 birth- matched inpatients (M-age : 64 years ± 8.6 ; 10 females).
No patient was re-admitted in either group. Post- surgical complications included one hematoma resorbed at 6 weeks in the outpatient group and three joint effusions in the inpatient group. There were no instances of deep venous thrombosis, failure of primary fixation, infection, or wound dehiscence. Knee mobility was identical between the two groups.
This is the first study to compare inpatient and outpatient total knee arthroplasty in a Belgian setting. Our study suggests that day-care total knee arthroplasty in selected patients is possible without increasing the rate of re-admission and complications, and without affecting the mobility at 6 weeks. However, the Belgian financial incentives do not seem to currently promote this surgical approach. These results should be confirmed with a larger sample to define the adequate length of stay after a total knee arthroplasty.
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Oosting E, Kapitein PJC, de Vries SV, Breedveld E. Predicting short stay total hip arthroplasty by use of the timed up and go-test. BMC Musculoskelet Disord 2021; 22:361. [PMID: 33863323 PMCID: PMC8052837 DOI: 10.1186/s12891-021-04240-6] [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: 11/26/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background One of the most important steps before implementing short stay total hip arthroplasty (THA) is establishing patient criteria. Most existing criteria are mainly based on medical condition, but as physical functioning is associated with outcome after THA, we aim to evaluate the added value of a measure of physical functioning to predict short-stay THA. Methods We used retrospective data of 1559 patients who underwent an anterior THA procedure. Logistic regression analyses were performed to study the predictive value of preoperative variables among which preoperative physical functioning by use of the Timed Up and Go test (TUG) for short stay THA (< 36 h). The receiver operating characteristic (ROC) curve and Youden Index were used to define a cutoff point for TUG associated with short stay THA. Results TUG was significantly associated with LOS (OR 0.84, 95%CI 0.82–0.87) as analyzed by univariate regression analysis. In multivariate regression, a model with the TUG had a better performance with an AUC of 0.77 (95%CI 0.74–0.79) and a R2 of 0.27 compared to the basic model (AUC 0.75, 95%CI 0.73–0.77, R2 0.24). Patients with a preoperative TUG less than 9.7 s had an OR of 4.01 (95%CI 3.19–5.05) of being discharged within 36 h. Conclusions Performance based physical functioning, measured by the TUG, is associated with short stay THA. This knowledge will help in the decision-making process for the planning and expectations in short stay THA protocols with the advantage that the TUG is a simple and fast instrument to be carried out.
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Affiliation(s)
- Ellen Oosting
- Department of Orthopedics, Hospital Gelderse Vallei, Willy Brandtlaan, 10 6716 RP, Ede, the Netherlands. .,Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands.
| | - Paul J C Kapitein
- Department of Orthopedics, Hospital Gelderse Vallei, Willy Brandtlaan, 10 6716 RP, Ede, the Netherlands
| | - Suzan V de Vries
- Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Ellen Breedveld
- Department of Physiotherapy, Hospital Gelderse Vallei, Ede, the Netherlands
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Defining Outpatient Hip and Knee Arthroplasties: A Systematic Review. J Am Acad Orthop Surg 2021; 29:e410-e415. [PMID: 32925385 DOI: 10.5435/jaaos-d-19-00636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 07/26/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient." METHODS A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty" identified 76 studies; 35 studies that met the inclusion criteria were assessed to determine the definition of "outpatient." The level of evidence, type of arthroplasty, location of surgery (hospital or ambulatory surgery center [ASC]), approach used for hip arthroplasty, number of patients, number of surgeons, and length of time the patients were kept at the location after surgery were evaluated. RESULTS Arthroplasties analyzed were total hip (11), total knee (seven), unicompartmental knee (five), and hip and knee (12). Only 16.8% of surgeries defined as outpatient hip or knee arthroplasty were done in a freestanding ASC, and 44.2% of patients defined as outpatients were kept overnight for the 23-hour observation. DISCUSSION We propose "DASH" (Discharge from ASC to Home) as a new term to define arthroplasties done in an outpatient setting with the patient discharged home the same day.
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