Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty

Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained

BACKGROUND

This study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital.

METHODS

A consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022).

RESULTS

The mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery.

CONCLUSIONS

Our study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Multimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

Patients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates.

CONCLUSIONS

Adding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

The influence of direct anterior approach and postero-lateral approach on wound complications after total hip arthroplasty: A meta-analysis

To date, we have reviewed the synthesis literature critically through four databases: PubMed, Embase, Cochrane Library and Web of Science. Eight relevant studies were examined after compliance with the criteria for inclusion and exclusion, as well as documentation quality evaluation. This report covered all randomised, controlled studies of total hip arthroplasty (THA) comparing the direct anterior approach (DAA) with the postero-lateral approach (PLA). The main result was surgical site infection rate. The secondary results were duration of the operation, length of the incision and VAS score after surgery. The results of the meta-analyses of wound infections in the present trial did not show any statistically significant difference in DAA versus PLA (between DAA and PLA) (OR = 1.42, 95%CI: 0.5 to 4.04, p = 0.51). Compared with PLA, DAA had shorter surgical incision (WMD = -3.2, 95%CI: -4.00 to -2.41; p < 0.001) and longer operative times(WMD = 14. 67, 95%CI: 9.24 to 20.09; p < 0.001). Postoperative VAS scores were markedly lower in DAA compared with PLA within 6 weeks of surgery (p < 0.05), with low heterogeneities(I2  = 0). We found that DAA did not differ significantly from PLA in terms of the risk of wound infection for THA and that the surgical incisions was shorter and less postoperative pain after surgery, even though DAA surgery takes longer.

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

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

Safe driving recommendations following lower extremity orthopedic surgery: a systematic review

PURPOSE

We analyzed the published literature on return-to-driving (RTD) recommendations following lower extremity orthopedic surgery, including knee and hip arthroplasty and ankle and foot surgery.

METHODS

We conducted a PubMed MEDLINE database search for the relevant literature spanning from 1988 to 2022. Data were extracted from the selected articles independently by six investigators, and the mean, standard deviation, and range of RTD recommendations for each surgical region and procedure were calculated.

RESULTS

The 34 studies included in our review evaluated brake response time, reaction time, movement time, braking force, and other parameters. Average RTD recommendations in weeks were: hip surgeries, 4.1 (± 2.7); foot surgeries, 6.67 (± 0.94); Achilles surgeries, 6.67 (± 0.25); ankle surgeries, 4 (± 2); knee surgeries, 5.42 (± 0.77); and multiple lower extremity surgeries, 3.85 (± 0.15).

CONCLUSION

Our findings can assist physicians in providing informed recommendations to patients, promoting safe driving practices, and optimizing postoperative recovery.

LEVEL OF EVIDENCE

Therapeutic, Level III: Retrospective comparative study.

Enhanced U-Net with GridMask (EUGNet): A Novel Approach for Robotic Surgical Tool Segmentation

This study proposed enhanced U-Net with GridMask (EUGNet) image augmentation techniques focused on pixel manipulation, emphasizing GridMask augmentation. This study introduces EUGNet, which incorporates GridMask augmentation to address U-Net's limitations. EUGNet features a deep contextual encoder, residual connections, class-balancing loss, adaptive feature fusion, GridMask augmentation module, efficient implementation, and multi-modal fusion. These innovations enhance segmentation accuracy and robustness, making it well-suited for medical image analysis. The GridMask algorithm is detailed, demonstrating its distinct approach to pixel elimination, enhancing model adaptability to occlusions and local features. A comprehensive dataset of robotic surgical scenarios and instruments is used for evaluation, showcasing the framework's robustness. Specifically, there are improvements of 1.6 percentage points in balanced accuracy for the foreground, 1.7 points in intersection over union (IoU), and 1.7 points in mean Dice similarity coefficient (DSC). These improvements are highly significant and have a substantial impact on inference speed. The inference speed, which is a critical factor in real-time applications, has seen a noteworthy reduction. It decreased from 0.163 milliseconds for the U-Net without GridMask to 0.097 milliseconds for the U-Net with GridMask.

Identifying Preoperative Predictors for 24-Hour Discharge After Elective Hip and Knee Arthroplasties

Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.

Assessment of Patient Satisfaction and Outcomes After Outpatient Joint Arthroplasty in Academic Medical Centers

Background

There is limited literature evaluating patient satisfaction and outcomes after outpatient joint arthroplasty procedures in academic medical centers (AMCs). The aims of this study are to determine: (1) patients' desires to repeat their procedures and be discharged on the same day, (2) patient-reported outcome measures (PROMs), (3) time to discharge, (4) readmission rates, and (5) factors that predict PROMs in patients undergoing outpatient joint arthroplasty in AMCs.

Methods

A prospective survey was completed by 66 total hip arthroplasty (THA), 35 total knee arthroplasty (TKA), and 180 unicondylar knee arthroplasty (UKA) outpatients who underwent surgery from May 2018 to December 2020 in 2 AMCs. The survey consisted of questions regarding hip or knee PROMs (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement), satisfaction with outpatient procedures and discharges, and reasons for readmissions. Linear regression analysis was conducted with statistical significance set at P < .05.

Results

100% of THA, 93.8% of TKA, and 93.0% of UKA outpatients stated that they would re-elect to undergo their respective procedure. Furthermore, 94% of THA, 81% of TKA, and 95% of UKA patients stated they would like same-day discharge again. THA, TKA, and UKA patients reported respective mean PROM scores of 94.7, 89.9, and 86.1. Readmission rates were 1.5%, 0.0%, and 0.5%, for THA, TKA, and UKA, respectively.

Conclusions

Patients who underwent outpatient joint arthroplasty procedures at 2 AMCs experienced minimal readmissions and reported a high desire to repeat their outpatient procedures.

Total Hip Arthroplasty: An Update on Navigation, Robotics, and Contemporary Advancements

While total hip arthroplasty (THA) remains effective for improvement of pain and function in patients with osteoarthritis and avascular necrosis, there remain areas of continued pursuit of excellence, including decreasing rates of dislocation, leg length discrepancy, implant loosening, and infection. This review article covers several bearing surfaces and articulations, computer-assisted navigation and robotic technology, and minimally invasive surgical approaches that have sought to improve such outcomes. Perhaps the most significant improvement to THA implant longevity has been the broad adoption of highly cross-linked polyethylene, with low wear rates. Similarly, navigation and robotic technology has proven to more reproducibly achieve intraoperative component positioning, which has demonstrated clinical benefit with decreased risk of dislocation in a number of studies. Given the projected increase in THA over the coming decades, continued investigation of effective incorporation of technology, soft tissue-sparing approaches, and durable implants is imperative to continued pursuit of improved outcomes in THA.

Efficacy of Adding Acetaminophen to Preemptive Multimodal Analgesia in Total Knee Arthroplasty: A Double-blinded Randomized Study

OBJECTIVE

Preemptive multimodal analgesia is a frequently utilized method for controlling pain after total knee arthroplasty (TKA). So far, no studies have specifically examined the efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA. The current work aimed to assess the efficacy of adding acetaminophen to preemptive multimodal analgesia for clinical pain management after TKA.

METHODS

This was a double-blinded randomized study including 80 cases randomized to the acetaminophen and control groups, respectively. The acetaminophen group was administered celecoxib at 400 mg, pregabalin at 150 mg, and acetaminophen at 300 mg 2 h before TKA. Control patients were administered celecoxib, pregabalin, and placebo. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes included the time to the initial rescue analgesia, postsurgical pain as determined by a visual analogue scale (VAS), functional recovery as reflected by the range of knee motion and ambulation distance, hospitalization duration, and complication rates. Continuous data with normal and skewed distributions were compared by the Student's t test and the Mann-Whitney U test, respectively. Categorical variables were compared by the Pearson's chi-squared test.

RESULTS

The control and acetaminophen groups were comparable in postoperative 0-24 h morphine consumption (11.3 ± 6.5 mg vs 12.3 ± 7.7 mg, P = 0.445) and total morphine consumption (17.3 ± 10.1 mg vs 19.3 ± 9.4 mg, P = 0.242). Additionally, time to the initial rescue analgesia, postoperative VAS score at any time point, postoperative functional recovery of the knee, and hospitalization duration were similar in both groups. Both groups also had similar occurrence rates of postoperative complications.

CONCLUSIONS

In this study, adding acetaminophen to preoperative preemptive multimodal analgesia did not decrease postoperative morphine use or ameliorate pain relief. The efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA need to be further explored in future studies.

Is It Necessary to Wake Patients for Overnight Vital Signs Following Total Joint Arthroplasty?

Benefits of sleep are well-established in postoperative recovery; however, patients undergoing total joint arthroplasty (TJA) often experience poor sleep during hospitalization. While multifactorial, among the major reasons are the frequent and ritualized overnight vital sign checks. In the absence of data in support of or against this practice, we asked whether it remains necessary. We retrospectively analyzed a cohort of 419 primary TJA patients. Demographics, comorbidities, operative, and vital sign data were collected through postoperative Day 3. Correlation between daytime (6:00 a.m. to 10:00 p.m.) and nighttime (10:01 p.m. to 5:59 a.m.) vitals was examined. The vast majority of nighttime vitals fell within normal ranges, including O2 saturation (O2; 99.4%), temperature (TEMP; 97.8%), heart rate (HR; 87.5%), systolic blood pressure (SBP; 85.8%), and diastolic blood pressure (DBP; 84.4%). Predictors of abnormal nighttime vitals included American Society of Anesthesiologists (ASA) score (abnormal SBP; odds ratio [OR] 1.64, p = .045), obesity (abnormal DBP; OR: 0.37, p = .011), and smoking status (elevated temperature; OR: 2.79, p = .042). Estimated blood loss was predictive of an abnormal nighttime TEMP (OR: 1.002; p < .001). Postoperatively, there were several correlations between abnormal daytime and nighttime vitals, including SBP (OR: 6.23, p < .001), DBP (OR: 4.31, p < .001), and HR (OR: 10.35; p < .001). Of the 419 patients, only 9 (2.1%) received any intervention based on abnormal nighttime vitals. Each exhibited daytime vital sign abnormalities prior to the abnormal nighttime readings. Patients with abnormal nighttime vitals can be predicted on the basis of medical comorbidities and abnormal daytime vitals. These findings suggest that healthy post-TJA patients with normal daytime vitals may not need to be routinely woken at night.

Modernizing Our Understanding of Total Hip Arthroplasty in the Pediatric and Young Adult Patient: A Single-center Experience

INTRODUCTION

Pediatric hip disorders represent a broad range of pathology and remain a significant source of morbidity for children and young adults. Surgical intervention is often required for joint preservation, but when salvage is not possible, joint replacement may be indicated to eliminate pain and preserve function. Although there have been significant updates in the management of both pediatric hip disease and the field of total hip arthroplasty (THA), there is a paucity of literature reflecting advancements in the area of pediatric and young adult (PYA) arthroplasty. No study has investigated the impact of approach on outcomes after PYA THA. The purpose of this study is to describe the indications, techniques, and early outcomes of THA in the PYA population in a modern practice setting.

METHODS

We performed a retrospective descriptive analysis of all patients undergoing primary THA performed at a tertiary care children's hospital from 2004 to 2019. Ninety-three hips in 76 patients were evaluated. Demographics, intraoperative variables, postoperative pain and function ratings, and complication and revision rates were collected.

RESULTS

Eighty-five hips in 69 patients were included. Patients were aged 12 to 23 years old, with males and females represented equally (33 vs. 36, respectively). The most common cause of hip pain was avascular necrosis (AVN, 56/85, 66%), most commonly due to slipped capital femoral epiphysis (13/56, 23%) idiopathic AVN (12/56, 21%), and chemotherapy (12/56, 21%). Half of all hips had been previously operated before THA (43/85). Thirty-six procedures were performed via the posterolateral approach (36/85, 42%), 33 were performed via direct anterior approach (33/85, 39%), and 16 were performed via the lateral approach (LAT, 16/85, 19%). At final follow-up, 98% (83/85) of patients had complete resolution of pain, 82% (70/85) had no notable limp, and 95% (81/85) had returned to all activities. There were 6 complications and 1 early revision. Average Hip disability and Osteoarthritis Outcomes Score for Joint Replacement scores increased by 37 points from 56 to 93. The overall revision-free survival rate for PYA THA was 98.8% (at average 19-mo follow-up).

CONCLUSIONS

Modern PYA THA is dissimilar in indications and surgical techniques to historic cohorts, and conclusions from prior studies should not be generalized to modern practice. In our practice, PYA patients most commonly carry a diagnosis of AVN, and THA can be performed with modern cementless fixation with large cup and head sizes and ceramic-on-cross-linked polyethylene bearings utilizing any approach. Further study is required to better characterize middle-term and long-term results and patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV-retrospective case series.

Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05.

RESULTS

Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis.

CONCLUSIONS

The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR.

LEVEL OF EVIDENCE

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

Return to work following primary total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is increasingly common in younger patients, who are more likely to be working preoperatively. There is a need for an updated review of the literature regarding the rate and time to return to work (RTW), which is important when counseling patients, and also from an economic standpoint.

METHODS

A systematic review and meta-analysis of the literature was performed on January 20, 2022, and studies reporting the rate and/or time to RTW after THA were included. Two authors independently selected relevant papers. RTW was extracted and analyzed using fixed-effects or random-effects models where appropriate.

RESULTS

A total of 48 studies were included in the final analysis. We found that 70.7% of patients were working after primary THA. Among patients who were working before surgery, this rate increases to 87.9%, while 28.1% of patients who were not working preoperatively started working after surgery. Younger patients were more likely to RTW, while patients with a physically demanding job were less likely to RTW. Minimally invasive techniques were reported to yield a higher rate of RTW and an earlier time to RTW.

CONCLUSION

We found that the majority of patients return to work after THA, and some patients are able to start working after surgery. Compared to previous reviews, patients seem to have a higher rate and earlier RTW. The overall trend of the literature suggests that patients are returning to work earlier and at a higher rate compared to previous reviews.

The use of an individualized intraoperative video shows no impact on the early postoperative clinical outcome after total knee arthroplasty: a prospective, randomized, controlled trial

PURPOSE

The purpose of the study was to evaluate the potential of an intraoperatively recorded video shown to patients immediately postoperatively on early outcome after total knee arthroplasty (TKA). The hypothesis was that there is a beneficial outcome concerning range of motion (ROM) and patient-reported outcome due to enhanced trust into the artificial joint.

METHODS

Seventy-three patients were randomly assigned 1:1 to two study groups in which they were either shown a video of their own postoperative range of motion or they were not. Clinically, the New Knee Society Score (nKSS) and ROM were evaluated and compared between the groups 6 weeks after surgery. Chi-square exact test, Kolmogorov-Smirnov test, Mann-Whitney U test, and the Wilcoxon signed rank test were used. Inter- and intra-class correlations were calculated for measurements of ROM.

RESULTS

No clinically relevant differences were observed preoperatively and 6 weeks postoperatively between both groups in range of motion (ROM). All patients were showing a significantly improved clinical outcome 6 weeks after the procedure. Clinical scores showed statistically significant differences with respect to preoperative nKSS for satisfaction and statistically significant differences with respect to postoperative nKSS for function.

CONCLUSION

Showing a video filmed immediately after implantation of primary TKA had no significant effect on ROM and clinical outcome at 6 weeks. We believe that face-to-face verbal communication in combination with video-assisted education ensures that patients understand their artificial joint in the best possible way and will continue to use intraoperatively filmed videos to enhance patient engagement during postoperative rehabilitation.

LEVEL OF EVIDENCE

I.

Doctor when can I drive? A systematic review and meta-analysis of return to driving after total hip arthroplasty

BACKGROUND/OBJECTIVE

Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons' recommendations range between 4-8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively.

METHODS

A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis.

RESULTS

14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant (p < 0.05).Studies not meeting meta-analysis inclusion criteria were included in a qualitative analysis, examining self-reported postoperative driving return times which ranged from 6 days to over a year or in rare cases, never. Majority of patients (n = 960) self-reported driving return within approximately 6 weeks (pooling of mean values 32.9 days).

CONCLUSIONS

The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.

Is an "Outpatient Arthroplasty Risk Assessment Score" Needed for Predicting Safe Selection of Outpatient Arthroplasty Candidates?

BACKGROUND

Total joint arthroplasty is rapidly shifting to the outpatient space. One of the challenges of same-day discharge adoption has been determining which patients are suitable candidates. Risk assessment tools have been developed, including the Outpatient Arthroplasty Risk Assessment (OARA) score. The purpose of this study was to assess its predictive utility.

METHODS

A retrospective review was performed on all total joint arthroplasties performed at a single ambulatory surgery center in 2018, yielding a cohort of 1,105 patients (1,332 arthroplasties). The institution's outpatient criteria required optimization of all medical conditions; if the patient had no failing organ, they were candidates for same-day discharge. OARA scores were calculated based on preoperative histories and physical examinations. Analyses were performed on the statistical utility of the OARA score in predicting successful same-day discharge. The mean age was 59 years (range, 27-82), the mean body mass index was 33.3 kg/m² (range, 16-66), and 51.5% were women. A total of 45% of patients had one or more major comorbidity.

RESULTS

There were 81.6% of patients who had an acceptable OARA score (<60). In addition, 97% of patients who had an "unacceptable" OARA score were successfully discharged the same day. There were 23 patients who required inpatient observation; of these, 7 (30.4%) had an OARA score ≥60.

CONCLUSION

The OARA score was accurate in predicting patients who successfully had same-day discharge but poor at predicting who would not. This system is time consuming and may be too restrictive on which patients are candidates for outpatient arthroplasty. Surgeons may consider a more simplified criteria for outpatient arthroplasty.

Medial bicompartmental arthroplasty patients display more normal gait and improved satisfaction, compared to matched total knee arthroplasty patients

PURPOSE

Medial bicompartmental arthroplasty, the combination of ipsilateral medial unicompartmental and patellofemoral arthroplasty, is an alternative to total knee arthroplasty for patients with medial tibiofemoral and severe patellofemoral arthritis, when the lateral tibiofemoral compartment and anterior cruciate ligament are intact. This study reports the gait and subjective outcomes following medial bicompartmental arthroplasty.

METHODS

Fifty-five subjects were measured on the instrumented treadmill at top walking speeds, using standard metrics of gait. Modular, single-stage, medial bicompartmental arthroplasty subjects (n = 16) were compared to age, body mass index, height- and sex-matched healthy (n = 19) and total knee arthroplasty (n = 20) subjects. Total knee arthroplasty subjects with pre-operative evidence of tricompartmental osteoarthritis or anterior cruciate ligament dysfunction were excluded. The vertical component of ground reaction force and temporospatial measurements were compared using Kruskal-Wallis, then Mann-Whitney test with Bonferroni correction (α = 0.05). Oxford Knee and EuroQoL EQ-5D scores were compared.

RESULTS

Objectively, the medial bicompartmental arthroplasty top walking speed of 6.7 ± 0.8 km/h was 0.5 km/h (7%) slower than that of healthy controls (p = 0.2), but 1.3 km/h (24%) faster than that of total knee arthroplasty subjects (5.4 ± 0.6 km/h, p < 0.001). Medial bicompartmental arthroplasty recorded more normal maximum weight acceptance (p < 0.001) and mid-stance forces (p = 0.03) than total knee arthroplasty subjects, with 11 cm (15%) longer steps (p < 0.001) and 21 cm (14%) longer strides (p = 0.006). Subjectively, medial bicompartmental arthroplasty subjects reported Oxford Knee Scores of median 41 (interquartile range 38.8-45.5) compared to total knee arthroplasty Oxford Knee Scores of 38 (interquartile range 30.5-41, p < 0.02). Medial bicompartmental arthroplasty subjects reported EQ-5D median 0.88 (interquartile range 0.84-0.94) compared to total knee arthroplasty median 0.81 (interquartile range 0.73-0.89, p < 0.02.) CONCLUSION: This study finds that, in the treatment of medial tibiofemoral osteoarthritis with severe patellofemoral arthritis, medial bicompartmental arthroplasty results in nearer-normal gait and improved patient-reported outcomes compared to total knee arthroplasty.

LEVEL OF EVIDENCE

III.

Driving performance and turning reaction time following hip arthroscopy for FAIS: does capsular repair matter?

PURPOSE

(1) To compare the pre- and postoperative driving performance in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); (2) to examine the differences in driving performance between patients with versus without capsular repair.

METHODS

Patients who underwent arthroscopic hip surgery for FAIS were included. Driving performance of participating patients was collected using a driving simulator preoperatively and at 2 weeks, 4-6 weeks and 8-12 weeks postoperatively. Data collected included demographics, surgery laterality, intraoperative procedures, left and right turn reaction time, total turn reaction time, gas off time (GOF), and break reaction time (BRT). Repeated measures analysis of variance (ANOVA) was used for statistical analysis.

RESULTS

21 subjects (9 males, 12 females) with a mean age of 30 ± 9 years were included and 57.1% of the subjects had right-sided surgery. There was no difference between the mean preoperative and the 2-week postoperative left (0.72 seconds and 0.75 seconds, respectively) right (0.77 seconds and 0.75 seconds, respectively), and total (0.74 seconds and 0.75 seconds, respectively) turn reaction times as well as GOF (0.62 seconds and 0.60 seconds, respectively) and BRT (0.92 seconds and 0.93 seconds, respectively), indicating that the patients' driving performance returned to the preoperative level as early as 2 weeks following hip arthroscopy for FAIS. There was no significant difference amongst any of the driving variables between patients who underwent capsular repair (50%) and those who did not. There was no significant difference amongst any of the driving variable s between patients who underwent left versus right hip arthroscopy.

CONCLUSIONS

Patients' driving performance returns to the preoperative level as early as 2 weeks after hip arthroscopy for FAIS. Surgery laterality nor capsular repair make any significant difference in the time for driving abilities to return to baseline. The impact of intraoperative procedures performed, and the analgesic medications used postoperatively on the driving ability of patients undergoing hip arthroscopy warrants further investigation in larger patient populations.

Efficacy of Opioids in Preemptive Multimodal Analgesia for Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Preemptive multimodal analgesia is a commonly used technique to control pain following total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of pre-emptive opioids for pain management in patients who underwent TKA.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to the oxycodone or control group. At 2 hours before surgery, patients in the oxycodone group received 400 mg celecoxib, 150 mg pregabalin, and 10 mg extended-release oxycodone hydrochloride. Patients in the control group received 400 mg celecoxib, 150 mg pregabalin, and placebo. The primary outcome was postoperative consumption of morphine hydrochloride as rescue analgesia. Secondary outcomes were time to first rescue analgesia, postoperative pain assessed by the visual analogue scale, functional recovery assessed by range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

The 2 groups were similar in mean postoperative 0 to 24 hour morphine consumption (11.4 mg for control versus 12.4 mg for oxycodone group, P = .419) and mean total morphine consumption (18.2 versus 19.8 mg, P = .227). There were no statistical differences in secondary outcomes.

CONCLUSIONS

In our study, preemptive opioid administration did not provide clinical benefits over placebo. Orthopaedic surgeons should consider not using pre-operative opioids in patients undergoing TKA.

Is the Anterolateral or Posterolateral Approach More Effective for Early Postoperative Recovery after Minimally Invasive Total Hip Arthroplasty?

Currently, various minimally invasive surgical techniques are applied for total hip arthroplasty (THA). There are few studies comparing the early postoperative clinical outcomes of minimally invasive THA between anterolateral and posterolateral approaches. In this retrospective study, 62 patients underwent minimally invasive THA via either the anterolateral approach with an intermuscular exposure using the modified Watson-Jones approach (MIS-AL, 34 hips) or mini-incision THA with a posterolateral approach (MIS-PL, 28 hips). We analyzed intraoperative data, postoperative hematological data, postoperative radiographic findings, and the postoperative recovery of muscle strength. The mean surgical time was significantly longer in the MIS-PL than in the MIS-AL group. The mean postoperative serum C-reactive protein level was significantly higher in the MIS-PL group than in the MIS-AL group only on postoperative day 3. There were no significant between-group differences in the postoperative recovery rate of muscle strength during hip abduction. The recovery rate of muscle strength during hip extension was better in the MIS-AL group than in the MIS-PL group only on postoperative day 3. In conclusion, we found no obvious advantage in early postoperative recovery between the MIS-AL and MIS-PL approaches. Therefore, the benefit of rapid postoperative recovery was comparable between the MIS-AL and MIS-PL approaches.

Online Crowdsourcing Survey of United States Population Preferences and Perceptions Regarding Outpatient Hip and Knee Arthroplasty

BACKGROUND

Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty.

METHODS

A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed.

RESULTS

In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA.

CONCLUSION

Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities.

Changes in serum creatine kinase and C-reactive protein after posterior and direct anterior approaches in total hip arthroplasty

PURPOSE

Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation.

MATERIALS AND METHODS

We prospectively recruited 71 women who were undergoing total hip arthroplasty, 47 were treated by the PA and 24 by the DAA. Serum CK and C-reactive protein (CRP) levels were measured preoperatively and 3 hours and 1, 4, 7, 10, and 14 days after the operation.

RESULTS

The serum CK levels were significantly higher in the DAA group than in the PA group on postoperative days 1, 4, 7, 10, and 14. On postoperative day 4 and 7, the percentage of patients whose serum CK levels were above the normal range was 46.8% and 8.5% in the PA group and 95.2% and 45.5% in the DAA group.

CONCLUSIONS

CK levels were significantly higher in the 2 weeks after THA by a DAA than after the same procedure by a PA indicating that DAA causes prolonged muscle damage. Although the DAA is considered to be a muscle-sparing approach this may not be the case and DAA may not actually be a minimally-invasive approach.

The ABLE Anterior-Based Muscle-Sparing Approach: A Safe and Effective Option for Total Hip Arthroplasty

Background

The direct anterior and posterior approaches are well-researched options in total hip arthroplasty (THA). The less-studied anterior-based muscle-sparing approach, also known as the ABLE advanced anterior approach, centers on minimizing surgical trauma and medical costs while maintaining or improving patient outcomes.

Material and methods

THAs performed using the ABLE approach by 3 surgeons at a single institution between January 2013 and August 2020 were retrospectively assessed for outcomes pertaining to safety and performance intraoperatively, perioperatively, and postoperatively. Additionally, intraoperative and postoperative complications were evaluated, and patient-reported outcome measures and radiographic outcomes out to 1-year follow-up.

Results

There were 6251 THAs (5433 patients) eligible for inclusion. The mean surgical time was 65 minutes, mean intraoperative blood loss was 204 mL, and the transfusion rate was 0.5%. Patients had a mean length of stay of 1.4 days. Overall, 93.4% of patients were discharged home, 1.9% visited the emergency department within 30 days, and 2.9% had an unplanned readmission to the hospital within 90 days. The overall major surgical complication rate was 1.18%, with a dislocation rate of 0.13%, a deep infection rate of 0.19%, and a postoperative periprosthetic fracture rate of 0.37%.

Conclusions

The minimally invasive ABLE approach is a safe and effective surgical approach for patients undergoing THA. It can be performed efficiently and with limited complications, making it an appealing option for surgeons to utilize during this era of value-based care.

Combined and Modified Gibson and Ilioinguinal Approaches in Type II + III Internal Hemipelvectomy for Periacetabular Tumors

Background

The routine iliofemoral approach and its modifications in type II+III resection require extensive skin incision and massive periacetabular muscle detachment, leading to prolonged hospital stay, increased complication incidence, and impaired lower limb function. Under the management of an enhanced recovery after surgery (ERAS) protocol, a combined and modified Gibson and ilioinguinal (MGMII) approach was used to avoid unnecessary soft tissue trauma during tumor resection and therefore advantageous to patients’ return to normal life.

Methods

Twenty-five patients with type II + III (including type II) periacetabular tumors who underwent reconstruction with 3D printed customized endoprostheses at our center between January 2017 and March 2019 were included in this study. There were 13 cases using MGMII approach and 12 cases using iliofemoral approach. The operation duration and blood loss were assessed by chart review. The surgical margin was evaluated by the histopathological studies. The reconstruction accuracy, the abductor muscle strength, the 1993 version of the Musculoskeletal Tumor Society (MSTS-93), the Harris Hip scores (HHS), and the limp score were evaluated. Complications were recorded after reviewing the patients’ records.

Results

The operative duration and blood loss in MGMII group were shorter than those in the iliofemoral group, but the postoperative hemoglobin was slightly higher than that in the iliofemoral group. The MGMII group had stronger postoperative hip abductors, better functional restoration, and relatively fewer patients with higher limp scores. No complication was observed in the MGMII group. In the iliofemoral group, three patients encountered wound healing delay, and one patient suffered deep infection.

Conclusions

The MGMII approach can better expose the posterior column of the acetabulum, especially the ischial tuberosity, which is beneficial for avoiding tumor rupture during resection. The MGMII approach also helps to preserve residual muscle function, such as the origin of the gluteus medius, while ensuring the extent of resection.

Location of Initial Closed Reduction Attempt Significantly Increases Cost and Length of Stay in Total Hip Arthroplasty

Background

Prosthetic hip dislocation remains one of the most frequent complications following total hip replacement. Dislocations are predominantly managed by a closed reduction in the emergency department (ED) or the operating room (OR). This study aimed to evaluate how the location of an initial closed reduction attempt impacts a patient's course of care including length of stay (LOS) and cost of care.

Material and methods

A retrospective chart review was performed on all patients presenting to a single ED with a unilateral prosthetic hip dislocation from 2009 to 2019. A total of 108 patients were identified. Data collected included patient demographics, ED/hospital course, and hospital charges.

Results

Seventy-four patients (69%) had initial reduction attempted in the ED (65/74, 88% were successful), while 34 patients (31%) went directly to OR (100% successful with closed reduction). Failed closed reduction in ED or direct to OR resulted in a greater LOS and rate of placement to a skilled nursing facility following discharge. Median hospital charges for successful ED reduction were $6,837, while failed ED closed reduction or direct to OR resulted in median charges of $27,317 and $20,481, respectively.

Conclusion

Many patients successfully underwent closed reduction in the ED, and there was no difference in complications, independent of where the reduction was first performed. Patients undergoing reduction in the OR had greater LOS and cost of care, independent of whether a reduction attempt was performed and failed in the ED, than those successfully reduced in the ED.

John N. Insall Award: MARCQI's Pain-Control Optimization Pathway (POP): Impact of Registry Data and Education on Opioid Utilization

BACKGROUND

In 2019, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) recommended an evidence-based opioid pain pathway to participating physicians and hospitals for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to determine if the education could influence and have lasting effects on the prescribing patterns for TJA patients.

METHODS

Using the MARCQI database, the number of oral morphine equivalents (OMEs) prescribed at discharge were collected from January 2018 through December 2019 for all primary arthroplasty procedures. Periods compared included before and after July 2018 Michigan opioid laws as well as before and after the March 2019 MARCQI recommendations. The data compared total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, opioid-naive vs opioid-tolerant patients, individual surgeons, and MARCQI sites.

RESULTS

The data included 84,998 TJAs: 22,774 opioid-naive THAs, 9124 opioid-tolerant THAs, 40,882 opioid-naive TKAs, and 12,218 opioid-tolerant TKAs. In all the groups and at all time periods there were a significant decrease in prescriptions (P < .001). Individual surgeons and participating sites also demonstrated decreased OMEs on discharge after the recommendations. Between the first and last months of collection, this represented an overall decrease of opioid OMEs for THA by 47.1% for opioid-naive patients and 53.4% for opioid-tolerant patients. For TKA patients, the OME decrease was 48.3% for opioid-naive patients, and 48.4% for opioid-tolerant patients.

CONCLUSION

The MARCQI pain control optimization pathway (POP) program has been successful in drastically reducing opioid prescribing with lasting effects, which has substantially limited the overall opioid prescription burden for patients undergoing arthroplasty.

Factors influencing the outcomes of minimally invasive total hip arthroplasty: a systematic review

Introduction

The present systematic review investigated possible factors which may influence the surgical outcome of minimally invasive surgery for total hip arthroplasty (MIS THA).

Methods

In January 2022, the Embase, Google Scholar, PubMed, and Scopus databases were accessed. All the clinical trials investigating the clinical outcome of MIS THA were considered.

Results

Data from 9486 procedures were collected. Older age was moderately associated with greater Visual Analogue Scale (VAS) (P = 0.02) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (P = 0.009) at last follow-up, and shorter surgical duration (P = 0.01). Greater body mass index (BMI) at baseline was moderately associated with greater cup anteversion (P = 0.0009), Oxford Hip Score (OHS) at last follow-up (P = 0.04), longer surgical duration (P = 0.04), increased leg length discrepancy (P = 0.02), and greater rate of infection (P = 0.04). Greater VAS at baseline was weakly associated with greater VAS at last follow-up (P < 0.0001), total estimated blood lost (P = 0.01), and lower value of Harris Hip Score (HHS) (P = 0.0005). Greater OHS at baseline was associated with greater post-operative VAS (P = 0.01). Greater WOMAC at baseline was associated with lower cup anteversion (P = 0.009) and greater VAS (P = 0.02). Greater HHS at baseline was associated with shorter hospitalisation (P = 0.001).

Conclusion

Older age and greater BMI may represent negative prognostic factors for MIS THA. The clinical outcome is strongly influenced by the preoperative status of patients.

Tranexamic acid reduces blood loss in primary total hip arthroplasty performed using the direct anterior approach: a one-center retrospective observational study

BACKGROUND

It is still unknown whether tranexamic acid (TXA) is beneficial for the minimally invasive surgical approach to total hip arthroplasty (THA). The aim of this study is to investigate the efficacy and safety of intravenous TXA in primary THA via the direct anterior approach (DAA).

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data on 70 patients with nontraumatic avascular necrosis of the femoral head who underwent THA via the DAA between October 2017 and October 2018. Patients were divided into two groups: TXA group (39 patients received 1.5 g TXA intravenously) and control group (31 patients did not receive TXA). Patients were assessed by operative time, postoperative hemoglobin (HB) drop, transfusion rate, postoperative length of hospital stays (LHS), deep vein thrombosis (DVT), and Harris hip score (HHS).

RESULTS

Total blood loss, hidden blood loss, and postoperative HB drop in the TXA group were significantly lower than in the control group (p < 0.05). There was no statistical difference between the two groups in terms of intraoperative blood loss, operative time, transfusion rate, postoperative LHS, HHS, or incidence of DVT (p > 0.05).

CONCLUSIONS

TXA may reduce perioperative blood loss without increasing complications in THA via the DAA.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts.

METHODS

The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05.

RESULTS

Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use.

DISCUSSION

Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA.

LEVEL OF EVIDENCE

Level IV; systematic review.

Effect of total hip arthroplasty on brake reaction time and braking force

INTRODUCTION

The correct moment for return to driving after total hip arthroplasty (THA) remains unclear. Until today no uniform recommendation exists on the ability to perform an emergency brake.The aim of this prospective study was to investigate the braking ability of patients before and after THA implantation based on brake reaction time in milliseconds (BRT) and braking force in N (BF).

METHODS

In total, 25 patients (15 men, 10 women, mean age 51.3 ± 10.1 years) were treated with THA on the right side. Inclusion criteria consisted of a valid driving licence, frequent road participation and at least 2 years of driving experience. Exclusion criteria were underlying neurological disorders as well as severe complaints in the lumbar spine and the right knee joint. The brake ability was evaluated for emergency braking with a car simulator and a measuring sole. Measurements were performed preoperatively, 6 days, 2, 4 and 6 weeks after surgery.

RESULTS

Preoperatively, the mean BRT was 671.3 ± 123.5 ms and the BF 455.4 ± 185.0 N. Significant differences were observed at 6 days and 2 weeks after surgery, (BRT 836.4 ± 219.7 ms, respectively, BRT 735.0 ± 186.7 ms, and BF 302.6 ± 154.9 N, respectively, BF 375.5 ± 149.3 N, p < 0.05). Only 4 weeks after, no significant differences were seen compared to pre-operative with a BRT of 647.0 ± 91.9ms (p = 0.354) and BF of 435.9 ± 177.4 (p = 0.843). Furthermore, the BRT improved significantly after 6 weeks (607.4 ± 87.6; p = 0.005).

CONCLUSIONS

The braking force is significantly reduced, and the brake reaction time is prolonged directly after surgery for at least 2 weeks. After 4 weeks, no statistically significant differences were measured, although special care should still be taken during return to activity.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Retrospective cohort study.

No benefits of minimally invasive total hip arthroplasty via Watson-Jones approach: A retrospective cohort study

INTRODUCTION

There is controversy about the role of minimally invasive surgery (MIS) for total hip arthroplasty (THA). The present study aimed to investigate whether a MIS approach has a positive impact on the outcome of THA via the Watson-Jones anterolateral approach. Clinical scores and radiological findings of minimally and standard invasive exposures were evaluated and compared.

METHODS

The present study was conducted according to the STROBE statement. Patients operated between 2017 and 2018 in two different orthopaedic institutions was performed. Patients with symptomatic coxarthrosis reducing considerably patient's quality of life were asked to participate in the present study. Patients were divided into two THA groups: MIS and standard invasive surgery (SIS). Surgical procedures were performed in by two experienced surgeons via the Watson-Jones approach.

RESULTS

Data from 140 patients were collected (70 patients for each group) at two years follow-up. Leg length discrepancy was greater in the MIS cohort (P = 0.01). The Stiffness subscale of the WOMAC score resulted minimally increased in the SIS group (P = 0.03). The overall WOMAC score and the other subscales resulted similar between the two groups. Femoral offset, acetabular offset, cup orientation, cup inclination, VAS resulted similar between the two cohorts. Only a case of revision in the SIS group was reported.

CONCLUSION

THA via the Watson-Jones approach achieves short terms excellent results. Surgery performed via a MIS approach does not provide any superior outcome compared to the SIS in terms of radiographic findings and clinical scores at two years follow-up.

Worse Preoperative Pain and Higher Activity Levels Predict Patient Choice of Formal Physical Therapy After Primary Anterior Total Hip Arthroplasty

BACKGROUND

The purpose of this randomized controlled trial is (1) to compare the efficacy of supervised formal physical therapy (PT) and self-directed home exercises and (2) to identify independent predictors of transitioning from self-directed home exercises to supervised formal PT following total hip arthroplasty (THA) via an anterior approach.

METHODS

After Institutional Review Board approval, 147 patients undergoing primary unilateral THA through anterior approach were enrolled and randomized to receive either clinic or home-based PT. Surveys with Hip Disability Osteoarthritis Outcome Scores (HOOS) and Short Form-12 Health Survey scores for both groups were obtained before surgery and at 6, 14, and 24 weeks after surgery. Patients had the option to transition into the other study group at their 6-week follow-up visit.

RESULTS

Of the 147 patients enrolled, final analysis included scores for 136 patients. Forty-two (63.6%) of the 66 patients randomized to the supervised formal PT group crossed over to self-directed home exercise group and 12 (17.1%) of the 70 patients randomized to the self-directed home exercise group crossed over to supervised formal PT group. There were no significant (P > .05) differences between groups at all time points for the overall HOOS and Short Form-12 Health Survey. Subjects with worse preoperative pain scores (P = .005) and higher HOOS preoperative activity of daily living scores (P = .015) were more likely to transition from the home exercise group to formal PT group.

CONCLUSION

There were no significant outcome score differences between subjects undergoing supervised formal PT and self-directed home exercises. However, patients reporting worse preoperative pain and higher preoperative activity levels may prefer supervised formal PT compared to self-directed home exercises after undergoing primary anterior THA.

Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures

BACKGROUND

Outpatient joint arthroplasty is a potential modality for increased case throughput and is rising in demand. However, we are aware of no study that has compared outcomes between risk-matched outpatient and inpatient procedures within the last 7 years. The aims of this study were to compare matched patient cohorts who underwent outpatient or inpatient joint arthroplasty in terms of 30-day adverse events and readmission rates.

METHODS

From the National Surgical Quality Improvement Program database, we identified patients who underwent primary total hip arthroplasty (THA), primary total knee arthroplasty (TKA), and primary unicompartmental knee arthroplasty (UKA) from 2009 to 2018. Using 10 perioperative variables, patients who underwent an outpatient procedure were 1:4 propensity score-matched with patients who underwent an inpatient procedure. The rates of 30-day adverse events and readmission were compared using the McNemar test. The risk factors for adverse events and readmissions were identified using multivariate regression.

RESULTS

Of 574,375 patients identified, 21,506 (3.74%) underwent an outpatient procedure. After propensity score matching, an outpatient joint arthroplasty was associated with a lower rate of adverse events (3.18% compared with 7.45%; p < 0.001). When assessed individually, outpatient TKA (3.15% compared with 8.11%; p < 0.001), THA (4.94% compared with 10.05%; p < 0.001), and UKA (1.78% compared with 3.39%; p < 0.001) were all associated with fewer adverse events overall and there was no difference in the rate of 30-day readmission, when compared with inpatient analogs. Outpatient joint arthroplasty was an independent factor for lower adverse events (odds ratio [OR], 0.407 [95% confidence interval (CI), 0.369 to 0.449]; p < 0.001), with no increase in the risk of readmission (OR, 1.004 [95% CI, 0.878 to 1.148]; p = 0.951).

CONCLUSIONS

Contemporary outpatient joint arthroplasty demonstrated lower rates of adverse events with no increased rate of 30-day readmission when compared with risk-matched inpatient counterparts. Although multiple factors should guide the decision for the site of care, outpatient arthroplasty may be a safe alternative to inpatient arthroplasty.

LEVEL OF EVIDENCE

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

Time Required for Planned and Unplanned Episodes of Care in Primary Total Joint Arthroplasty: Has Anything Changed With a Growth in Outpatient Arthroplasty?

BACKGROUND

This study sought to determine the total amount of time committed to planned and unplanned episodes of care related to primary, unilateral total joint arthroplasty (TJA), relative to a growth in outpatient TJA.

METHODS

All primary, unilateral TJA procedures performed over a 7-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. All telephone inquiries and readmissions involving the surgeon's direct input, over the episode of care, constituted time dedicated to unplanned work.

RESULTS

Between 2012 and 2018, as the proportion of outpatient TJAs increased, the average planned episode-of-care time per patient decreased from 412 minutes to 361 minutes. Despite a 108% increase in the total number of outpatient TJAs between 2017 and 2018 (51/432 (11.8%) to 106/555 (19.1%); P = .002), neither the average number of unplanned telephone inquiries (4.6 ± 3.8 vs 4.2 ± 3.7; P = .124), nor the mean time per patient required to respond to calls (23.1 ± 19.4 vs 21.2 ± 18 minutes, P = .135) differed. Between 2017 and 2018, the average total episode-of-care time per patient decreased from 403 minutes (376 planned + 27 unplanned) to 387 minutes (361 planned + 26 unplanned).

CONCLUSION

Despite an increase in outpatient TJA, the average time required for planned and unplanned patient care remained relatively constant. The growth of outpatient TJA nationally should not trigger a change in Centers for Medicare and Medicaid Services benchmarks.

Single-Stage Bilateral Total Hip Arthroplasty in an Ambulatory Surgical Center: A Report of Three Cases

In recent years, there has been increased interest in transitioning total joint arthroplasty procedures from inpatient settings to ambulatory surgical centers to decrease costs and eliminate the need for hospital stays. In addition, simultaneous bilateral total hip arthroplasty (THA) has been found to be favorable in certain patient populations when compared with staged bilateral THA. In this study, we report the results of a series of three patients who underwent single-stage bilateral THA in a free-standing ambulatory surgical center with excellent short-term outcomes and no 90-day complications.

Short-stem total hip arthroplasty is not associated with an earlier return to work compared to a straight-stem design

Return to work (RTW) has been specifically identified as a high priority in patients undergoing total hip arthroplasty (THA). This investigation sought to assess the effect of the stem design on patients' RTW. Secondly, the study aimed to identify risk factors that lead to a delayed RTW. Questionnaires inquiring about RTW, employment history, educational level, type of work, physical demands and joint awareness were administered by post. Further data were collected from patients' hospital records. 176 patients who underwent THA using a short-stem and 97 patients using a straight-stem design were compared. The median return to work time was 10 weeks [IQR 7-14 weeks], with no significant difference between the two groups (short stems vs. straight stems; 10 [IQR 7-14] vs. 11 [7.5-13.5] weeks; p = 0.693). In the multivariate linear regression analysis, self-employment vs. employee (p = 0.001), dimension of preoperative workload (p = 0.001), preoperative sick leave (p < 0.001), and hospital length of stay (LOS) (p < 0.001) independently affected the period until work was resumed. The Forgotten-Joint-Score-12 showed no significant difference between the two groups. The data show that the majority of THA patients can expect to resume work and stem design has no impact on RTW. Employees with preoperative sick leave, prolonged hospital LOS and low workload are at higher risk for a delayed RTW.

Minimally invasive direct anterior approach versus standard lateral approach in the management of tumors of the femoral neck

BACKGROUND

To compare the clinical outcomes of patients with benign or aggressive tumors of the femoral neck who underwent surgical curettage with the use of the direct anterior approach (DAA) and a standard lateral approach.

METHODS

Those patients from 2010 to 2017 were retrospectively enrolled. The patients were divided into two groups: group A, consisting of patients who had undergone surgery via the lateral approach; and group B, consisting of patients who had undergone the same procedure via the DAA.

RESULTS

Fifty-eight patients were divided into group A (n = 46) and group B (n = 12). The median follow-up was 43 months (15-97 months). There was no significant difference in the 1-year and 3-year recurrence rates (p = 0.74). Group B had comparable operation time and a significantly shorter incision length, less intraoperative blood loss, less postoperative drainage, a shorter hospital stay and less pain on the first postoperative day. Group B also had better hip function as assessed by the Harris Hip Score one month and one year postoperatively. One patient in group B experienced intraoperative incomplete fracture of the femoral neck, which was treated conservatively.

CONCLUSIONS

Surgical curettage for patients with benign or aggressive tumors of the femoral neck via the DAA had a comparable local control rate and a better perioperative and functional outcome than via the lateral approach. Certain quality of the femoral neck should be required to avoid pathological fracture, which is difficult to treat by internal fixation in the DAA.

Same-Day vs One-Day Discharge: Rates and Reasons for Emergency Department Return After Hospital-Based Total Joint Arthroplasty

BACKGROUND

As short stay and outpatient total joint arthroplasties (TJAs) are more widely adopted, it is important to assess whether reducing length of stay leads to increased emergency department (ED) visits or readmissions.

METHODS

This is a retrospective review of 1743 primary TJA patients with same-day discharge (SDD) or 1-day length of stay between January and December 2019. Patients who returned to the ED or were readmitted within 30 days of TJA were identified, and chart review was performed to identify their primary reason for revisit.

RESULTS

Patients discharged on the day of surgery (n = 203, 11.6%) were more likely to be younger (P < .001) and have a lower body mass index (total hip arthroplasty, P = .018; total knee arthroplasty, P < .001) and American Society of Anesthesiologists score (P < .001). The overall rate of return was 6.3%, and 1.3% of patients were readmitted. Controlling for age, gender, body mass index, surgery type, and American Society of Anesthesiologists, patients selected for SDD were not found to be at higher risk of return to the ED compared to 1-day length of stay patients (4.9% vs 6.4%, odds ratio 0.980, 95% confidence interval 0.484-1.984, P = .956).

CONCLUSION

SDD of eligible patients does not increase the risk of 30-day return to the ED. Continued analysis of risk factors for return and readmission will improve prospective identification of patients who can safely be discharged on the day of surgery, and future quality improvement initiatives should target the most common reasons for ED return.

Is two-incision approach superior to the mini-posterior approach in total hip arthroplasty?: a meta-analysis

BACKGROUND

Whether there is any clinical superiority for the two-incision total hip arthroplasty (THA) over the mini-posterior THA remains controversial. The present meta-analysis aimed to comprehensively compare the clinical outcomes between the two mini-invasive THAs.

METHODS

Two authors searched the database of Web of Science, PubMed, EMBASE and Cochrane Library to screen eligible studies individually. The quality evaluation of included studies was performed according to the principle of risk-of-bias of the Cochrane Library. The pooled results were analysed by Review Manager 5.3 software.

RESULTS

A total of seven prospective studies (including five randomized controlled trials) with 423 hips were finally included for meta-analysis. The pooled results revealed that the mini-posterior THA outperformed the two-incision THA in shortening operative times, reducing blood loss and postoperative fracture risks, while no significant difference was found between the two surgery methods with respect to HSS scoring, SF-12 scoring, postoperative function recovery and other postoperative complications.

CONCLUSION

Based on the pooled results, we suggested the mini-posterior THA as a preferable choice for patients suffering from severe advanced hip diseases.

Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?

BACKGROUND

Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA.

METHODS

1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions.

RESULTS

759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention.

CONCLUSION

Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.

Outcomes of outpatient total hip arthroplasty: a systematic review

INTRODUCTION

Similar to other total joint arthroplasty procedures, total hip arthroplasty (THA) is shifting to an outpatient setting. The purpose of this study was to analyse outcomes following outpatient THA.

METHODS

A comprehensive literature search was performed in April 2019 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Embase, and Cochrane databases to identify articles that reported functional outcomes following outpatient total hip arthroplasty (THA).

RESULTS

9 articles, with 683 hips and a collective study period of 1988 to 2016, were included in this analysis. The mean age across all studies was 58.9 years and the follow-up period ranged from 4 weeks to 10 years. 4 studies reported Harris Hip Scores (HHSs) for their patient populations and in 3 studies, the average HHSs were excellent (>90) by 6 weeks postoperatively. The fourth study reported fair HHS scores for the outpatient and inpatient THA groups (75 ± 18, 75 ± 14, p = 0.77, respectively) at 4 weeks postoperatively. VAS scores improved significantly in two studies and NRS at rest and during activity improved significantly (p < 0.001) in a separate study. Overall, 88.1% of the enrolled patients were discharged the same day of surgery, as expected. Out of the 6 studies reporting on readmissions rate, there were two (0.34%) readmissions within 3 months of surgery.

CONCLUSION

In patients with no significant comorbidities, outpatient THA leads to favourable outcomes as well as low readmission rates in the short term.

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

BACKGROUND

Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later).

METHODS

In total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups.

RESULTS

In total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m². There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545).

CONCLUSION

Using modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness.

Heterotopic ossification in primary total hip arthroplasty using the posterolateral compared to the direct lateral approach

PURPOSE

Total hip arthroplasty (THA) is a successful procedure. However, in time, heterotopic ossification (HO) can form due to, amongst others, soft tissue damage. This can lead to pain and impairment. This study compares the formations of HO between patients who underwent either THA with the posterolateral approach (PA) or with the direct lateral approach (DLA). Our hypothesis is that patients who underwent THA with a PA form less HO compared to THA patients who underwent DLA.

METHODS

In this prospective cohort study, 296 consecutive patients were included who underwent THA. A total of 127 patients underwent THA with the PA and 169 with the DLA. This was dependent on the surgeon's preference and experience. More than 95% of patients had primary osteoarthritis as the primary diagnosis. Clinical outcomes were scored using the Numeric Rating Scale (NRS) and Harris Hip Score (HHS), radiological HO were scored using the Brooker classification. Follow-up was performed at 1 and 6 years postoperatively.

RESULTS

Two hundred and fifty-eight patients (87%) completed the 6-year follow-up. HO formation occurred more in patients who underwent DLA, compared to PA (43(30%) vs. 21(18%), p = 0.024) after 6 years. However, the presence of severe HO (Brooker 3-4) was equal between the DLA and PA (7 vs. 5, p = 0.551). After 6 years the HHS and NRS for patient satisfaction were statistically significant higher after the PA (95.2 and 8.9, respectively) compared to the DLA (91.6 and 8.5, respectively) (p < 0.001 and p = 0.003, respectively). The NRS for load pain was statistically significant lower in the PA group (0.5) compared to the DLA group (1.2) (p = 0.004). The NRS for rest pain was equal: 0.3 in the PA group and 0.5 in the DLA group.

CONCLUSION

THA with the PA causes less HO formation than the DLA.

TRIAL REGISTRATION

Registrated as HipVit trial, NL 32832.100.10, R-10.17D/HIPVIT 1. Central Commission Human-Related research (CCMO) Registry.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients With Pneumonia

IMPORTANCE

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Physical and occupational therapists help improve functional mobility and may be of help in this population.

OBJECTIVE

To evaluate whether use of physical and occupational therapy in the acute care hospital is associated with 30-day hospital readmission risk or death.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included the electronic health records and administrative claims data of 30 746 adults discharged alive with a primary or secondary diagnosis of pneumonia or influenza-related conditions from January 1, 2016, to March 30, 2018. Patients were treated at 12 acute care hospitals in a large health care system in western Pennsylvania. Data for this study were analyzed from September 2019 through March 2020.

EXPOSURES

Number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6).

MAIN OUTCOMES AND MEASURES

Outcomes were 30-day hospital readmission or death. Generalized linear mixed models were estimated to examine the association of therapy use and outcomes, controlling for patient demographic and clinical characteristics. Subgroup analyses were conducted for patients older than 65 years, for patients with low functional mobility scores, for patients discharged to the community, and for patients discharged to a post-acute care facility (ie, skilled nursing or inpatient rehabilitation facility).

RESULTS

Of 30 746 patients, 15 507 (50.4%) were men, 26 198 (85.2%) were White individuals, and the mean (SD) age was 67.1 (17.4) years. The 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95% CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95% CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95% CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting.

CONCLUSIONS AND RELEVANCE

In this study, the number of therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Outpatient vs. inpatient hip arthroplasty: a matched case-control study on a 90-day complication rate and 2-year patient-reported outcomes

BACKGROUND

The transition to outpatient-based surgery is a major development occurring in recent years in the field of total hip arthroplasty (THA). The effect of this transition on patient-reported outcomes (PROs) is still not well established. The purpose of the current study was to compare patients undergoing inpatient THA (iTHA) to patients undergoing outpatient THA (oTHA) regarding (1) perioperative variables including surgical time, blood loss, and length of stay (2) 90-day complication rates and unplanned emergency room or office visits (3) 2-year PROs including modified Harris hip score (mHHS), Harris hip score (HHS), forgotten joint score (FJS), pain, and satisfaction, as well as the quality of live measures.

METHODS

The American Hip Institute registry was analyzed for patients undergoing THA between July 2014 and April 2016. The first 100 patients undergoing oTHA were selected and matched to 100 patients undergoing iTHA via propensity matching based on the following variables: age, sex, body mass index (BMI), Charlson comorbidity index (CCI), and smoking status. The primary outcomes were PROs at 2 years post-operatively. The secondary outcomes were perioperative surgical variables, 90-day complication rates, and unplanned emergency and clinic visits.

RESULTS

After exclusions, 91 patients remained in each group and were compared. The oTHA group showed improved 2-year PROs with regard to mHHS (91.5 vs. 86.2; P = 0.02), HHS (92.3 vs. 87.4; P = 0.02), and pain (1.0 vs. 1.5; P = 0.04). The oTHA group had an average length of stay of 6.8 h compared to 43.2 h for the iTHA group (P < 0.001). There were no significant differences between the groups regarding readmissions, emergency room visits, and unplanned clinic visits. Complications and revision rates were similar in both groups.

CONCLUSION

In appropriately selected, younger patients, oTHA can achieve improved postoperative 2-year PROs compared to iTHA. We found no differences regarding postoperative short-term complications or 2-year revision rates, and no differences in unplanned office visits or readmissions.

LEVEL OF EVIDENCE

Prognostic level 3.

Learning Curve for the Direct Superior Approach to Total Hip Arthroplasty

Surgical learning curves are a representation of the number of cases required for a surgeon to reach a stable rate of outcomes and complications. In this study, the authors present the learning curve for the direct superior (DS) approach to total hip arthroplasty, which is a muscle-sparing modification to the mini-posterior technique. This was a retrospective analysis of the first 40 primary DS cases done by a single surgeon. These cases were divided into 2 groups of 20 and compared for intra- and postoperative complications, acetabular component positioning, and Harris Hip Score at 90 days after surgery. As a control, the first 20 primary mini-posterior cases were analyzed as the baseline performance of the surgeon and the DS approach. There was no statistically significant difference between the first and second sets of DS patients regarding Harris Hip Score, intraoperative complications, dislocations, estimated blood loss, length of hospital stay, and components positioned within the Lewinnek safe zone. The only statistically significant difference between the first and second sets of DS cases was a decrease in operating time (P<.001). This suggests that the learning curve is less than 20 patients. The results also indicate that the first 20 DS cases ambulated farther (P=.007) and had a shorter length of stay (P=.007), outperforming the mini-posterior approach. This study suggests that the DS learning curve is short for surgeons trained in the posterior approach. The data could be especially pertinent as 90-day results and safety are becoming increasingly important in evaluating performance for bundled-payment models. [Orthopedics. 2020;43(4):e237-e243.].

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

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