The constraints on day-case total knee arthroplasty: the fastest fast track

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BACKGROUND

The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA).

METHODS

There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours).

RESULTS

In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer.

CONCLUSIONS

Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Day-case hip and knee arthroplasty: stages of care and the development of an institutional pathway

Day-case, or outpatient, arthroplasty is growing and has been adopted in healthcare systems because of its cost-effectiveness. A number of studies that reported on day-case total hip arthroplasty, total knee arthroplasty and unicompartmental knee arthroplasty have shown that they can be performed successfully in a select group of patients. However, safety remains a concern, as a clear pathway, including discharge criteria, is not well described in the literature. This article outlines the stages of care involved in day-case hip and knee arthroplasty and gives insights from University College London Hospital's own evidence-based day-case arthroplasty pathway.

Fast-track surgery and telerehabilitation protocol in unicompartmental knee arthroplasty leads to superior outcomes when compared with the standard protocol: a propensity-matched pilot study

BACKGROUND

Several strategies have been devised to reduce the length of stay after orthopedic surgery. Telerehabilitation has proved effective in functional outcomes after orthopedic procedures and is appreciated by patients. There is limited information on fast-track surgery and telerehabilitation protocols for unicompartmental knee arthroplasty (UKA). The purpose of this pilot study was to report and compare functional outcomes and satisfaction levels during first 12 months of recovery in patients who underwent UKA according to a fast-track and telerehabilitation protocol (G1) or standard surgery and rehabilitation program (G2).

METHODS

Data were retrospectively collected and reviewed for all elective UKAs from January 2018 to November 2019. A total of seven patients undergoing UKA according to the fast-track and telerehabilitation protocol were propensity score matched (1:3 ratio) to 21 patients undergoing standard surgery and rehabilitation. Patients were matched for age, sex, body mass index (BMI), and laterality. The Western Ontario and McMaster University (WOMAC) osteoarthritis index and range of motion (ROM) were collected pre- and postoperatively in both groups for 12 months. In addition, patient' satisfaction was collected at 40 days.

RESULTS

The G1 group demonstrated significantly better outcomes in WOMAC index scores at 2, 15, and 40 days (p < 0.001, p < 0.001, p < 0.020, respectively) and a significantly greater knee ROM after surgery and at 2, 15, 40, and 12 months (p < 0.001, p < 0.001, p = 0.014, p < 0.001, p = 0.003, respectively). No patients in either group had postoperative complications. One patient was not completely satisfied in the G2, while no one in G1 reported not being completely satisfied (p = 1.000).

CONCLUSIONS

This fast-track and telerehabilitation protocol after UKA can potentially be applied to patients as it is safe and effective. At 12-months follow-up, both groups reported favorable outcomes after UKA. However, the G1 score was better regarding WOMAC and ROM when compared with the propensity score-matched G2 program. A larger study is warranted to explore the role of fast-track and telerehabilitation in clinical and functional outcomes of UKA.

Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support "early" discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student's t test and for categorical data using χ² testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

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.

Introducing a day-case arthroplasty pathway significantly reduces overall length of stay

Aims

Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital.

Methods

A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway.

Results

Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001).

Conclusion

Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty.

Cite this article: Bone Jt Open 2021;2(11):900–908.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

PURPOSE

We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.

METHODS

200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.

RESULTS

166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%.

CONCLUSION

Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Influence of outpatient total knee arthroplasty compared to inpatient surgery on medical and economic outcomes

Firstly, this study compared the rate of readmission after a total knee arthroplasty between selected out- patients (no hospitalization, directly sent home after surgery) and inpatients (3 days hospitalization) at 6 weeks. Secondly, it examined the mobility and the complications in the two groups after the same period of time. The rate of readmission, complications and knee mobility of 32 outpatients (M-age : 61 years ± 10 ; 10 females), were compared against those of 32 birth- matched inpatients (M-age : 64 years ± 8.6 ; 10 females). No patient was re-admitted in either group. Post- surgical complications included one hematoma resorbed at 6 weeks in the outpatient group and three joint effusions in the inpatient group. There were no instances of deep venous thrombosis, failure of primary fixation, infection, or wound dehiscence. Knee mobility was identical between the two groups. This is the first study to compare inpatient and outpatient total knee arthroplasty in a Belgian setting. Our study suggests that day-care total knee arthroplasty in selected patients is possible without increasing the rate of re-admission and complications, and without affecting the mobility at 6 weeks. However, the Belgian financial incentives do not seem to currently promote this surgical approach. These results should be confirmed with a larger sample to define the adequate length of stay after a total knee arthroplasty.

Experience-optimised fast track improves outcomes and decreases complications in total knee arthroplasty

PURPOSE

The aim of this study was to describe an advanced total knee arthroplasty (TKA) fast-track programme and determine discharge parameters during hospitalisation, as well as patient satisfaction, outcomes and complications within the first 12 months after surgery.

METHODS

This prospective study was based on patients selected consecutively for primary elective TKA, undergoing surgery between 2014 and 2017 in an established fast-track setting. Hospitalisation-related parameters were collected: demographics, body mass index (BMI), surgical time, ischaemia time, haemoglobin values, blood transfusions, length of stay, weight-bearing and stair-climbing time, opioid administration, preoperative and discharge loss of extension and maximum active flexion of the knee, visual analogue scale (VAS), 12-month follow-up satisfaction rate and range of motion, any complications, hospital re-admission and re-operation within the first 12 months. Differences were determined using t-tests.

RESULTS

A total of 704 total knee replacements implanted in 481 patients were included in the study and 223 patients had a bilateral TKA. Their mean age was 69.8 years (range 57-88 years). At the 12-month follow-up, 623 patients (88.5%) reported being satisfied or very satisfied and 15 (2.1%) were dissatisfied with their TKA, mean active flexion and loss of extension were 104.4° and 2.3°, respectively. A total of 15 complications occurred (two percent): five painful knees, three knee stiffness, three haematomas, two infections, one hospital re-admission and one deep venous thrombosis. No cases of pulmonary embolism and death related to surgery were reported.

CONCLUSION

The study reports on an advanced fast-track programme for TKA with a low incidence of surgery- and hospitalisation-related issues and complications and without any severe adverse events during the first year. On average, the fast-track programme had a short length of stay, an early recovery of weight-bearing, knee mobility, pain control and a high satisfaction rate, accompanied with an acceptable 12 month range of motion.

Implementation of Outpatient Total Joint Arthroplasty in Canada: Where We are and Where We Need to Go

Total joint arthroplasties (TJA) are successful procedures for the treatment of end-stage hip and knee arthritis. Length of stay in hospitals after these procedures has been steadily decreasing over time, with outpatient procedures (discharge on the same day as surgery) introduced in the US within the last 20 years. Reducing length of stay after TJA can provide cost savings. Centres in Canada have started to utilize outpatient TJA procedures, but we have identified some barriers that may have limited their implementation. We have summarized the current literature for outpatient TJA and discussed potential solutions for the current barriers.

Outpatient Versus Rapid Recovery Inpatient Knee Arthroplasty: Comparison of Matched Cohorts

Increased focus on reducing the cost of total knee arthroplasty (TKA) has driven greater interest in performing the procedure in an outpatient setting. This study used exact matching to compare clinical and economic outcomes following TKA in an outpatient vs rapid recovery inpatient setting. This study used a nationally representative commercial database. Patients were grouped into 2 cohorts: same-day outpatient TKA (surgery center or hospital outpatient) or short-stay inpatient TKA ("rapid recovery"; length of stay 1 day or less). Only patients discharged home under self-care or with health care were included. Exact 1:1 matching was performed on clinical and demographic characteristics to control for potential case-selection bias by choice of care setting. Prior to matching, 969 outpatients and 8101 rapid recovery inpatients met selection criteria. The outpatient cohort was younger (median age, 58 vs 61 years), predominantly female (56% vs 51%), and less comorbid (Charlson Comorbidity Index score of 0: 84.2% vs 74.0%) vs the rapid recovery cohort. Post-match, 863 patients were available in each cohort. The outpatient cohort exhibited a significantly lower incidence of opiate use (80.4% vs 90.7%; P<.001) and minor complications (2.8% vs 5.8%; P=.002). Incidence of major complications (5.2% vs 6.7%, P=.173) and 90-day readmissions (5.1% vs 7.3%, P=.064) were equivalent. The outpatient median 90-day episode payment was $6824 lower (22%) per patient ($24,749 vs $31,573, respectively; P<.001). This study suggests that among carefully selected patients undergoing outpatient TKA, outcomes are equivalent, if not improved, at a lower payor cost compared with a rapid recovery inpatient setting. [Orthopedics. 2020; 43(1):36-41.].

Results of a fast-track knee arthroplasty according to the experience of a multidisciplinary team

Introduction

Fast-Track is a multidisciplinary system that has changed the perception of total knee arthroplasty surgery. It's based on the education of the patient, an increased autonomy, adequate pain control and early mobilization. In the bibliography, there are no articles that refer to the evolution of the protocol once established, and most of them are comparatives with the previously existing conventional system. For this reason, the objective of our work is to study the evolution of the clinical results obtained through a Fast-Track system according to the experience acquired by the multidisciplinary team in this protocol.

Material and methods

It's a prospective observational study. We have analyzed the results obtained in our center from its implementation in 2013 (n = 65) to the end of the study in 2016 (n = 60). We evaluated the pain at 24 and 48 h after surgery, the time until the first ambulation, the range of flexion and extension at discharge, and length of hospital stay.

Results

The results obtained at the beginning of the implantation of the Fast-Track protocol in our center and the present ones do not present statistically significant differences. Mean pain at 24 h was 1,65/10 in 2013 and 1,5/10 in 2016, and at 48 h 1,61/10 and 1,58/10 respectively. Most of the patients in both years scored a pain below 4/10 at 24 h and 48 h. Mean time of the first ambulation was 260 min in 2013 and 254 min in 2016 (most of the patients started walking in ≤5 h). Mean flexion at discharge was 90,3° in 2013 and 87,92° in 2016 (most of the patients presented a flexion between 80 and 100°). Mean extension at discharge was 6,95° in 2013 and 8,1° in 2016 (most of the patients presented an extension between 0 and 10°). Mean length of stay was 2,46 days in 2013 and 2,43 days in 2016 (most of the patients had a stay of fewer than 4 days).

Conclusions

When applying the Fast-Track protocol by a multidisciplinary team in primary knee prosthetic surgery, the clinical results obtained are independent of the experience of this team in the protocol. So, from our experience, we can affirm that the protocol has enough solidity since its beginning and it maintains similar results despite the years of execution.

Short-term outcomes of outpatient surgery for total knee arthroplasty

INTRODUCTION

We developed an accelerated clinical pathway involving outpatient surgery for patients undergoing total knee arthroplasty (TKA) who are healthy enough for early discharge.

METHODS

Between March 2014 and April 2015, 89 TKAs were performed at a single institution by a single orthopaedic surgeon. 31 patients met the inclusion criteria for the study. All patients received 2 g tranexamic acid and 750 mg cefuroxime sodium intravenously 30 minutes prior to surgery. A multimodal protocol for perioperative pain management was used for all patients.

RESULTS

31 patients (three male, 28 female), with a mean age of 67 (range 49-78) years, who underwent TKA were enrolled in this study. The mean length of hospital stay was 28.7 (range 16-49) hours and mean duration of surgery was 92 (range 75-128) minutes. Combined spinal epidural anaesthesia was performed for 23 (74.2%) patients and general anaesthesia was used in 8 (25.8%) patients. Among the 31 patients, 23 (74.2%) patients were discharged within 23 hours of surgery.

CONCLUSION

Early discharge of patients following outpatient surgery for TKA was not associated with any procedure-related complications among the selected patients up to three months postoperatively.

Outpatient total knee arthroplasty: Readmission and complication rates on day 30 in 61 patients

BACKGROUND

Total knee arthroplasty (TKA) on an outpatient basis is controversial due to concerns about patient safety. In France, only 1.1% of TKAs performed in 2017 were outpatient procedures. Nevertheless, recent advances in the multi-modal and multidisciplinary management of TKA patients combined with optimisation of the various components of perioperative care are increasing the use of outpatient TKA. However, studies on outcomes remain scarce. The primary objective of this work was to compare readmission rates within 30 days after TKA between patients managed as outpatients and as inpatients. The secondary objectives were to compare complication rates and patient satisfaction between the two groups.

HYPOTHESIS

After outpatient TKA, the day-30 rates of readmission and complications are similar to those seen after inpatient TKA.

MATERIAL AND METHODS

A retrospective single-centre study of consecutive patients who underwent TKA between April 2014 and July 2017 was performed. Readmissions, complications, and patient satisfaction were collected.

RESULTS

Of 574 patients, 61 were selected to undergo outpatient TKA and 513 had inpatient TKA. The day-30 readmission rate was 2/61 (3.3%) in the outpatient group and 25/513 (4.9%) in the inpatient group. The overall complication rate was 8% in the outpatients and 7.2% in the inpatients. The satisfaction rate was high in the outpatient group, with 80% very satisfied and 20% satisfied patients.

CONCLUSION

When performed in appropriately selected patients, outpatient TKA is not associated with a higher readmission rate compared to inpatient TKA.

LEVEL OF EVIDENCE

IV, retrospective comparative study.

Time-driven activity-based cost of outpatient total hip and knee arthroplasty in different set-ups

Background and purpose - Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced over the years due to fast-track. Short stays of 2 days in fast-track departments in Denmark have resulted in low total costs of around US$2,550. Outpatient THA and TKA is gaining popularity, albeit in a limited and selected group of patients; however, the financial benefit of outpatient arthroplasty remains unknown. We present baseline detailed economic calculations of outpatient THA and TKA in 2 different settings: one from the hospital and another from the ambulatory surgery department. Patients and methods - Data from 6 patients (1 TKA, 1 uncemented THA, 1 cemented THA in each department) were collected prospectively using the Time Driven Activity Based Costing method (TDABC). Time consumed by different staff members involved in patient treatment in the perioperative period of outpatient THA and TKA was calculated in 2 different settings: one in the orthopedic department and one in the ambulatory surgery department. Results - LOS was around 11 h in the orthopedic department and around 7 h in the ambulatory surgery department, respectively. TDABC revealed minor differences in the operative settings between departments and similar expenses occurred during the short stay of US$777 and US$746, respectively. Adding the preoperative preparation and postoperative follow-up resulted in total cost of US$951 and US$942 for the ward and the ambulatory surgery department, respectively. Interpretation - Outpatient THA and TKA in hospital and ambulatory surgery departments results in similar cost using the TDABC method. Compared with the cost associated with 2-day stays, outpatient procedures are around two-thirds cheaper provided no increase occurs in complications or readmissions.

No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: An observational before-and-after study of 14,148 total joint replacements 2011-2015

Background and purpose - Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods - Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011-2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results - Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation - Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.

Incidence and Risk Factors for Blood Transfusion in Simultaneous Bilateral Total Joint Arthroplasty: A Multicenter Retrospective Study

BACKGROUND

The aim of this study was to identify the incidence and risk factors for blood transfusion in patients undergoing simultaneous bilateral total hip arthroplasty (SBTHA) and simultaneous bilateral total knee arthroplasty (SBTKA).

METHODS

We identified 414 SBTHA and 1147 SBTKA procedures, and separated the patients into those who did and did not require allogeneic blood transfusion. A multivariate logistic regression model was used to identify independent risk factors for transfusion.

RESULTS

The transfusion rate after SBTHA was 50.0%, and significant risk factors for transfusion were female gender (odds ratio [OR] = 2.612), lower body mass index (OR = 1.093), inflammatory arthritis (OR = 1.970), American Society of Anesthesiologists (ASA) class ≥3 (OR = 3.477), drain use (OR = 4.607), and increased intraoperative bleeding. We also found that higher preoperative hemoglobin (Hb) and tranexamic acid use decreased the risk of transfusion. The transfusion rate after SBTKA was 29.1%, and significant risk factors for transfusion were ASA class ≥3 (OR = 8.959), tourniquet use (OR = 2.129), drain use (OR = 4.970), and increased intraoperative bleeding. A higher preoperative Hb was the only protective factor for transfusion.

CONCLUSION

For SBTHA, the risk factors included female gender, lower body mass index, inflammatory arthritis, ASA class ≥3, drain use, and increased intraoperative bleeding, while for SBTKA, risk factors were ASA class ≥3, tourniquet use, drain use, and increased intraoperative bleeding. Increasing the preoperative Hb level may decrease transfusion risk. In addition, tranexamic acid was encouraged to use to decrease transfusion need in SBTHA.

Outpatient total hip and knee arthroplasty

As a result of the introduction of fast-track programs, the length of hospital stay after arthroplasty has decreased to a point where some patients meet the discharge criteria on the day of surgery. In several studies, well-established fast-track centers have demonstrated the feasibility of outpatient procedures in selected patients. However, in literature the term "outpatient" is sometimes also used for patients who spend one or more nights in hospital. We therefore propose to use "outpatient" solely for patients who are discharged to their own home on the day of surgery and do not have an overnight stay at either the hospital or another non-home facility. Also, several challenges need to be overcome before this becomes an established procedure. The combination of preoperative high-dose steroids and multimodal opioid-sparing analgesia has enhanced patient recovery after arthroplasty, but efforts to control undesirable pathophysiological responses will be a prerequisite to improve the success rate of an outpatient setting. Also, care must be taken to avoid extra activities or investments solely to enable discharge on the day of surgery. Further cost analyses will have to be performed to establish the true financial benefit of outpatient treatment.

The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review

BACKGROUND

Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty.

METHODS

We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation.

RESULTS

Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again.

CONCLUSION

For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty: A Prospective, Randomized Controlled Trial

BACKGROUND

Tourniquet use during primary total knee arthroplasty is thought to reduce intraoperative blood loss and improve visibility. Our goal was to investigate whether tourniquet use is necessary for controlling intraoperative blood loss when alternatives such as tranexamic acid (TXA) are available.

METHODS

One hundred and fifty patients were equally randomized to 3 groups. Group A was treated with a tourniquet as well as multiple doses of intravenous TXA (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA, Group B was treated the same as Group A but without the tourniquet, and Group C was treated with the tourniquet only.

RESULTS

The amount of intraoperative blood loss was similar for the 3 groups. Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001). No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level. We also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction. There were no significant differences (p > 0.05) in the deep venous thrombosis or pulmonary embolus rates among the 3 groups. More wound secretion was observed in the groups in which a tourniquet was used.

CONCLUSIONS

Patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet. Long-term follow-up should be performed to evaluate the effects on prosthetic fixation and long-term survival of total knee arthroplasty performed without a tourniquet.

LEVEL OF EVIDENCE

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

Patient selection criteria for outpatient joint arthroplasty

PURPOSE

General consensus of patient selection criteria for outpatient joint arthroplasty is lacking, which is paramount to prevent prolonged hospital stay, adverse events and/or readmissions. This review highlights patient selection criteria for OJA based on the current literature and expert opinion.

METHODS

A search of the English and International electronic healthcare databases including MEDLINE/PubMed, EMBASE, AMED and the Cochrane library was performed in November 2015 to include studies published during the last 10 years. Furthermore, a survey of physicians from different specialties was performed.

RESULTS

Fourteen studies described results regarding outpatient joint arthroplasty. Studies on outpatient hip and/or knee arthroplasty resulted in similar outcome in preselected patients. Patients who are able and willing to participate, with a low ASA classification (<III), undergoing primary arthroplasty, age <75 and with support at home during the first postoperative days are eligible candidates for outpatient joint arthroplasty. Patients with a high ASA classification (>II), bleeding disorders, poorly controlled and/or severe cardiac (e.g. heart failure, arrhythmia) or pulmonary (e.g. embolism, respiratory failure) comorbidities, uncontrolled DM (type I or II), a high BMI (>30 m²/kg), chronic opioid consumption, functional neurological impairments, dependent functional status, chronic/end-stage renal disease and/or reduced preoperative cognitive capacity should be excluded from outpatient joint arthroplasty. The expert opinion-based selection criteria were comparable to literature with a further extension of exclusion for patients with practical issue's, urologic medical history and/or severe mobility disorders.

CONCLUSION

Based on the current literature, the presented patient selection criteria provide a basis for outpatient joint arthroplasty and can be useful when selecting patients. Together with a change in mindset, a multidisciplinary approach and literature-based protocols, outpatient joint arthroplasty can be applied in daily orthopaedic practice while ensuring patients' safety.

LEVEL OF EVIDENCE

Clinical review, Level III.

Safety Aspects of Postanesthesia Care Unit Discharge without Motor Function Assessment after Spinal Anesthesia

Background

Postanesthesia care unit (PACU) discharge without observation of lower limb motor function after spinal anesthesia has been suggested to significantly reduce PACU stay and enhance resource optimization and early rehabilitation but without enough data to allow clinical recommendations.

Methods

A multicenter, semiblinded, noninferiority randomized controlled trial of discharge from the PACU with or without assessment of lower limb motor function after elective total hip or knee arthroplasty under spinal anesthesia was undertaken. The primary outcome was frequency of a successful fast-track course (length of stay 4 days or less and no 30-day readmission). Noninferiority would be declared if the odds ratio (OR) for a successful fast-track course was no worse for those patients receiving no motor function assessment versus those patients receiving motor function assessment by OR = 0.68.

Results

A total of 1,359 patients (98.8% follow-up) were available for analysis (93% American Society of Anesthesiologists class 1 to 2). The primary outcome occurred in 92.2% and 92.0%, corresponding to no motor function assessment being noninferior to motor function assessment with OR 0.97 (95% CI, 0.70 to 1.35). Adverse events in the ward during the first 24 h occurred in 5.8% versus 7.4% with or without motor function assessment, respectively (OR, 0.77; 95% CI, 0.5 to 1.19, P = 0.24).

Conclusions

PACU discharge without assessment of lower limb motor function after spinal anesthesia for total hip or knee arthroplasty was noninferior to motor function assessment in achieving length of stay 4 days or less or 30-day readmissions. Because a nonsignificant tendency toward increased adverse events during the first 24 h in the ward was discovered, further safety data are needed in patients without assessment of lower limb motor function before PACU discharge.

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

BACKGROUND

There has been a recent surge of interest in performing primary total knee arthroplasty (TKA) in the outpatient setting to reduce cost and increase patient satisfaction. Detailed information on the safety of outpatient TKA in large sample sizes is scarce.

METHODS

Patients who underwent primary, elective TKA were identified in the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days, whereas inpatient procedure was defined as having a length of stay ≥1 days. To reduce the effect of confounding factors and nonrandom assignment of treatment, propensity score matching was used. Multivariate analyses on the matched samples were used to compare the rates of adverse events that happened any time during the 30-day postoperative period, postdischarge adverse events, and readmissions between the outpatient and inpatient cohorts.

RESULTS

A total of 112,922 TKA patients met the inclusion criteria. Of these, only 642 (0.57%) were outpatient procedures. Outpatients tended to be men, slightly younger, and have less comorbidity. After propensity matching, multivariate analysis revealed a higher rate of postdischarge blood transfusions (P < .001) in the outpatient cohort. There were no other significant differences in 30-day postoperative individual adverse events or readmissions.

CONCLUSION

Based on the perioperative outcome measures studied here, outpatient TKA can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients postdischarge may be warranted.

Fast track in hip arthroplasty

‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.

The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.

Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.

In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org

A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation

For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.

Developments in ambulatory surgery in orthopedics in France in 2016

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription.

Preoperative education prior to elective knee arthroplasty surgery does not change patient outcomes

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. There are few studies assessing the role of patient education. In our enhanced recovery programme, all patients are offered the chance to attend a preoperative education class. Not all patients attend, enabling a comparison of outcomes. We have published data demonstrating that patients undergoing hip arthroplasty have improved outcomes. In the present article, we present data for total knee arthroplasty. Using a prospectively collected database, we identified all patients undergoing elective primary total knee arthroplasty. Data were assessed to look at patient outcomes. This was analysed using non-parametric tests. Between April 2009 and March 2013, 563 patients underwent elective total knee replacement. A total of 503 attended the class and 60 did not. Patients attending had a reduced length of stay when compared with the non-attenders but this did not reach statistical significance (4.13 days versus 4.57 days; p = 0.118). The spread of length of stay was slightly larger in the group that attended. Our analysis demonstrated that, for these patients, there is no statistically significant difference in length of stay or outcome scores. Therefore, in tougher economic times it may be prudent to focus preoperative education on total hip arthroplasty patients if resources are limited.

Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty

BACKGROUND

The rate of total shoulder arthroplasty (TSA) is rising, which has an impact on health care expenditure. One avenue to mitigate cost is outpatient TSA. There are currently no published reports of this practice. In this study, we determine the 30-day adverse event and readmission rates after outpatient TSA and compare these rates with inpatient TSA.

METHODS

A retrospective cohort study using a population database in the United States was undertaken. Patients who underwent primary TSA between 2005 and 2014 were identified and divided into 2 cohorts based on length of stay (LOS): outpatient TSA (LOS 0 days) and inpatient TSA (LOS >0 days). Patient and procedure characteristics were collected. The 30-day adverse event and readmission rates were calculated for each cohort. A multivariate logistic regression determined if the odds of an adverse event or readmission were significantly different between the inpatient and outpatient TSA cohorts.

RESULTS

Overall, 7197 patients in this database underwent TSA between 2005 and 2014, of which 173 patients (2.4%) underwent outpatient TSA. The 30-day adverse event rate in the outpatient and inpatient TSA cohorts was 2.31% and 7.89%, respectively. The 30-day readmission rate in the outpatient and inpatient TSA cohorts was 1.74% and 2.93%, respectively. In the multivariate logistic regression, the odds of an adverse event or readmission were not significantly different (odds ratio of 0.4 [P = .077] and odds ratio of 0.7 [P = .623], respectively).

CONCLUSION

There are no significant differences in the 30-day adverse event and readmission rates between outpatient and inpatient TSA. In the appropriately selected patient, outpatient TSA is safe and cost-effective.

Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence?

Regional anesthesia for knee and hip arthroplasty may have favorable outcome effects compared with general anesthesia by effectively blocking afferent input, providing initial postoperative analgesia, reducing endocrine metabolic responses, and providing sympathetic blockade with reduced bleeding and less risk of thromboembolic complications but with undesirable effects on lower limb motor and urinary bladder function. Old randomized studies supported the use of regional anesthesia with fewer postoperative pulmonary and thromboembolic complications, and this has been supported by recent large non-randomized epidemiological database cohort studies. In contrast, the data from newer randomized trials are conflicting, and recent studies using modern general anesthetic techniques may potentially support the use of general versus spinal anesthesia. In summary, the lack of properly designed large randomized controlled trials comparing modern general anesthesia and spinal anesthesia for knee and hip arthroplasty prevents final recommendations and calls for prospective detailed studies in this clinically important field.