Patient Risk Factors Do Not Impact 90-Day Readmission and Emergency Department Visitation After Total Ankle Arthroplasty: Implications for the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Plan

Obesity is highly associated with a non-home discharge following total ankle arthroplasty

Studies have shown that non-home discharge following orthopedic procedures is associated with a higher risk of 30-day complications and significantly increases medical costs. The purpose of this study was to identify risk factors for being discharged to a non-home destination following total ankle arthroplasty (TAA). We included patients undergoing TAA from the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) between 2014 and 2019. TAA was identified using CPT codes 27702, 27703 and 27704. Logistic regression models were used to assess the association between discharge location (home versus non-home) and a series of exposure variables (e.g., patient demographics, patient health characteristics, and operative factors). A total of 1,704 patients were included, experiencing a 3.6% short term complication rate (61/1,704). 8.5% of the population were discharged to a non-home destination. In the final adjusted model, patients who were older [OR 1.11; 95%CI 1.08, 1.13], female [OR 2.94; 95%CI 2.04, 4.34], obese [OR 1.93; 95%CI 1.29, 2.89], had surgery in an inpatient setting [OR 5.73; 95%CI 1.78, 18.46], and ASA class IV [OR 10.65; 95%CI 1.03, 110.61] were at greater risk for a non-home discharge. People living with obesity experienced a nearly 2x greater likelihood of being discharged to a non-home destination after TAA despite their preoperative functional (e.g., ASA class) and metabolic status (i.e., diabetes). Opportunities to mitigate this risk will be needed to lessen the financial burden of TAA surgery as a growing number of obese patients become eligible for TAA in the US.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

The Effect of Frontal Deformity at the Ankle Joint on Total Ankle Arthroplasty Revision Rate

The presence of severe coronal plane deformity in the ankle joint is widely recognized as challenging to correct by total ankle joint arthroplasty alone, necessitating additional rearfoot fusion. The primary aim of this retrospective study was to investigate the potential associations between the presence or severity of coronal tibiotalar deformities and adverse outcomes after isolated total ankle arthroplasty, such as revisions and complications. The secondary aim was to analyze the potential associations between comorbidities, demographics, and implant types, and adverse outcomes. Our study's distinctive feature was its exclusive concentration on patients with deformities centralized in the ankle joint. Chart review was performed on 496 ankles in 456 patients who had a total ankle arthroplasty by 5 surgeons from 1/1/2010 to 12/31/2019. After exclusion and inclusion criteria were applied, total of 214 ankles in 210 patients were included for data analysis. At a mean follow-up period of 3 ± 2.0 years, our cohort had 15 (7.0%) revisions and 15 (7.0%) complications. Multivariable logistic regression model showed that the presence or severity of the coronal deformity was not significantly associated with incidences of revisions or complications. Female patients had significantly lower revision rate. Otherwise, the differences in age, race, body mass index, tobacco use, presence of diabetes, chronic kidney disease, atrial fibrillation, length of surgery, or type of implant were not significantly associated with incidences of revisions or complications. Further study could be performed to analyze the extent and duration that the coronal deformity correction is maintained after total ankle arthroplasty as well as the effect of each soft tissue procedure performed with the total ankle arthroplasty.

Obesity and Ankle Prosthesis Revision: A Systematic Review and Meta-analysis

BACKGROUND

The increasing number of total ankle arthroplasties (TAAs) has led to growing evidence on the risk factors for complications after surgery. However, the role of obesity in this patient group has been the subject of much debate. Therefore, this systematic review aimed to investigate the evidence for untoward effects of obesity following TAA.

METHODS

We conducted a comprehensive search on April 28, 2023, in MEDLINE (via PubMed), Embase, and CENTRAL. Eligible observational studies reported on the short- and long-term outcomes of primary TAA, comparing patients with and without obesity (defined as body mass index > 30). Using a random effects model, we calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) from 2 by 2 tables (event and nonevent in the obese and nonobese primary TAA groups).

RESULTS

Nine studies with 10 388 patients were eligible for inclusion in the meta-analysis. We found significantly higher odds of revision in the obese group compared to the nonobese group (OR = 1.68, CI: 1.44-1.95). However, the odds of overall perioperative complications (OR = 1.55, CI: 0.50-4.80) and wound complications (OR = 1.34, CI: 0.29-6.20) were nonsignificantly higher in the obese group.

CONCLUSION

Based on our results, obesity may have affected long-term outcomes following TAA and may have negatively affected the prosthesis's survival.

Patient-related risk factors associated with poorer outcomes following total ankle arthroplasty

Aims

This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

Methods

A scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-based literature search was performed in PubMed, Embase, Cochrane trials, and Web of Science. Two reviewers independently performed title/abstract and full-text screening according to predetermined selection criteria. English-language original research studies reporting patient-related factors associated with a poorer outcome following TAA were included. Outcomes were defined as patient-reported outcome measures (PROMs), perioperative complications, and failure.

Results

A total of 94 studies reporting 101,552 cases of TAA in 101,177 patients were included. The most common patient-related risk factor associated with poorer outcomes were younger age (21 studies), rheumatoid arthritis (17 studies), and diabetes (16 studies). Of the studies using multivariable regression specifically, the most frequently described risk factors were younger age (12 studies), rheumatoid arthritis (eight studies), diabetes (eight studies), and high BMI (eight studies).

Conclusion

When controlling for confounding factors, the most commonly reported risk factors for poor outcome are younger age, rheumatoid arthritis, and comorbidities such as diabetes and increased BMI. These patient-related risk factors reported may be used to facilitate the refinement of patient selection criteria for TAA and inform patient expectations.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value"

BACKGROUND

Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF).

METHODS

Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01).

RESULTS

There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001).

CONCLUSION

Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Thirty-Day Morbidity and Mortality in Patients With COPD Following Open Reduction and Internal Fixation for Rotational Ankle Fractures

Prior orthopedic literature has found patients with chronic obstructive pulmonary disease (COPD) to be at an increased risk for postoperative morbidity and mortality. Thus, the purpose of this study is to identify whether there are any differences in risk for 30-day morbidity or mortality following ORIF for ankle fractures between adult patients with COPD and without COPD. Patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database from 2006 to 2018. Patients were divided into 2 cohorts: non-COPD and COPD patients. In this analysis, demographics data, medical comorbidities, and thirty-day postoperative outcomes were analyzed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10,346 total patients who underwent operative treatment for ankle fracture, 9986 patients (96.5%) did not have a history of COPD whereas 360 (3.5%) had COPD. Following adjustment to control for demographic and comorbidity data, relative to patients without COPD, those with COPD had an increased risk of pneumonia (odds ratio [OR] 4.601; p = .001), unplanned intubation (OR 3.085; p = .043), and hospital readmission (OR 1.828; p = .020). Patients with COPD did not have a statistically significant difference with regards to mortality (OR 2.729; p = .080). Adult patients with COPD are at an increased risk for pneumonia, unplanned intubation, and hospital readmission within 30 days following ORIF of ankle fractures compared to patients without COPD. Despite these risks, this is a relatively safe procedure for these patients and the presence of COPD alone should not serve as a barrier to surgery.

Emergency Department Visits Within 90 Days of Total Ankle Replacement

Background

Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration.

Methods

This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits.

Results

Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) (P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem.

Conclusion

Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs.

Level of Evidence

Level III, retrospective cohort study.

Efficacy Analysis of Comprehensive Nursing in the Care of Ovarian Carcinoma Treated with Paclitaxel Combined with Nedaplatin

Objective

To determine the effectiveness of comprehensive nursing in the care of ovarian carcinoma (OC) patients treated with paclitaxel (PTX) plus nedaplatin (NDP).

Methods

The research population comprised 180 advanced OC patients who received treatment in the Shaanxi Cancer Hospital between November 2018 and November 2021. The enrolled cases were assigned to two groups based on different nursing plans: an observation group (OG) with 100 cases treated with comprehensive nursing and a control group (CG) with 80 cases intervened by conventional nursing. Intergroup comparisons were performed to identify statistical significance in terms of the following parameters: serum NGF, TK1, and CA15-3 levels; VAS, SAS, and SDS scores; nursing compliance; incidence of adverse reactions; and nursing satisfaction.

Results

Compared with CG, OG showed the following: (1) lower posttreatment NGF, TK1, and CA15-3 levels; (2) lower scores of SAS and SDS; (3) higher nursing compliance; and (4) lower incidence of adverse reactions and higher nursing satisfaction after nursing.

Conclusions

Comprehensive nursing far outperformed conventional nursing in the care of advanced OC patients treated with PTX plus NDP, which is worth popularizing.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship.

METHODS

This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data.

RESULTS

Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68).

DISCUSSION

Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies.

LEVELS OF EVIDENCE

Prognostic, Level III: Comparative study.

A Systematic Review and Meta-analysis of Total Ankle Arthroplasty or Ankle Arthrodesis for Treatment of Osteoarthritis in Patients With Diabetes

Background:

End-stage ankle osteoarthritis often requires one of 2 major surgical procedures: total ankle arthroplasty or ankle arthrodesis. Although the gold standard has been arthrodesis, patients with diabetes represent a unique cohort that requires additional considerations because of their decreased mobility and risk factors for cardiovascular complications. The purpose of this study is to review odds of major and minor adverse events for patients with diabetes and patients without diabetes in both total ankle arthroplasty and ankle arthrodesis.

Methods:

A total of 14 articles published between 2010 and 2020 were included in this review. Databases included PubMed, Scopus, MEDLINE/Embase, and Cochrane Library. Key words included ankle arthroplasty, total ankle arthroplasty, ankle arthrodesis, and diabetes.

Results:

The total number of procedures was 26 287, comprising 13 830 arthroplasty and 12 457 arthrodesis procedures. There was a significant association between patients with diabetes treated with arthrodesis and major adverse events (odds ratio [OR] 1.880, 95% CI 1.279, 2.762), whereas no significant association was observed between patients with diabetes treated with arthroplasty and major adverse events (OR 1.106, 95% CI 0.871, 1.404).

Conclusion:

This meta-analysis suggests patients with diabetes to be at significantly higher risk for major and minor adverse events after undergoing ankle arthrodesis. However, it suggests no significant differences in major adverse events between patients with diabetes and patients without diabetes having undergone total ankle arthroplasty.

Level of Evidence:

Level III, systematic review and meta-analysis.

Anemia Severity and the Risks of Postoperative Complications Following Total Ankle Arthroplasty

BACKGROUND

Although studies have demonstrated the effect of anemia severity on postoperative complications after arthroplasties of the shoulder, hip, and knee, no studies have investigated the effect on total ankle arthroplasty (TAA). The objective was to determine the influence of preoperative anemia severity on complications following TAA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2006 to 2019 for patients undergoing TAA. Utilizing the World Health Organization (WHO) definitions of anemia, patients were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate to severe anemia (hematocrit <33% for both women and men). Demographics, comorbidities, length of stay, and short-term (30-day) postoperative complications were compared between groups. Bivariate analyses, including χ2 and analysis of variance, and multivariable logistical regression were performed.

RESULTS

After exclusion, 1490 patients (1313 nonanemia [88.1%], 154 mild anemia [10.3%], and 23 moderate/severe anemia [1.6%]) were included. Increasing severity of anemia was associated with an increased average hospital length of stay (1.84 vs 2.19 vs 2.78 days, P < .001) and rate of reoperation (0.38% vs 3.90% vs 4.35%, P < .001). There was a statistically significant increase in wound disruptions (0.15% vs 1.95% vs 4.35%, P = .001), minor complications (1.52% vs 4.55% vs 8.70%, P = .008), major complications (1.98% vs 5.84% vs 4.35%, P < .033), and any complications (3.50% vs 10.39% vs 13.04%, P = .001) between groups. Multivariate analysis identified mild and moderate/severe anemia as a predictor of reoperation and extended length of stay (P ≤ .033).

DISCUSSION

Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TAA. Medical optimization prior to surgical intervention is necessary in patients undergoing TAA.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Level of Evidence

Level III, retrospective cohort study.

Decreased physical activity in patients with ankle osteoarthritis. A case-control study comparing daily step counts

BACKGROUND

The purpose of this study was to compare physical activity levels and the proportion of patients who met physical activity recommendations in patients with ankle osteoarthritis and controls.

METHODS

Ankle osteoarthritis patients (n = 50) and controls (n = 50) were recruited. physical activity was measured using an accelerometer-based monitor. Physical activity parameters, including the step count/day, the proportion of patients who met physical activity recommendations of ≥7000 steps/day, and moderate to vigorous physical activity minutes/day, were compared between the patient groups.

RESULTS

The patients with ankle osteoarthritis walked 3998 steps/day, while the controls walked 6531 steps/day (P < .001). Only 7 (14%) ankle osteoarthritis patients and 17 (34%) controls met the physical activity recommendations of ≥7000 steps/day (P =  .01). Time spent performing moderate to vigorous physical activity was 58 and 78 min/day in the ankle osteoarthritis and controls, respectively.

CONCLUSIONS

The physical activity level of ankle osteoarthritis patients was lower than that of controls. Only a limited proportion of ankle osteoarthritis patients met the physical activity recommendation.

Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA.

METHODS

We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty.

RESULTS

We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types.

CONCLUSION

Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Effect of comprehensive nursing on the pain, anxiety and malnutrition of hepatitis B patients

OBJECTIVE

To explore the effect of comprehensive nursing on pain, anxiety and malnutrition of hepatitis B patients.

METHODS

Totally 100 cases of hepatitis B patients received treatment in our hospital from July 2017 to July 2018 were divided into a study group (64 cases) and a control group (36 cases) for comprehensive nursing and routine nursing. The liver function, nutritional indexes, cognition of relevant nursing knowledge, VAS score, HAMD and HAMA scores, QOL score, total effective rate and incidence of adverse reactions were detected.

RESULTS

Compared with the control group, the study group had lower liver function indexes and higher nutrition indexes, suggesting that the liver function of patients in the study group recovered better. Besides, the VAS score of the study group was lower, suggesting better pain relief in the study group. Moreover, the study group had higher scores of related nursing knowledge and lower scores of HAMD and HAMA, indicating that the nursing method in the study group was more effective in reducing depression and anxiety. Higher QOL score, higher total effective rate and lower incidence of adverse reactions of the study group revealed that the nursing mode adopted in this group was better for the recovery of patients.

CONCLUSION

Comprehensive nursing can effectively alleviate the pain of hepatitis B patients, relieve their anxiety and other negative emotions, and improve their malnutrition.

Analysis of early failure rate and its risk factor with 2157 total ankle replacements

The failure rate of TAA is still higher than that of other joint replacement procedures. This study aimed to calculate the early failure rate and identify associated patient factors. Data from the Korean Health Insurance Review and Assessment Service database from 2009 to 2017 were collected. We evaluated patients who had TAA as a primary surgical procedure. Early failure was defined as conversion to revision TAA or arthrodesis after primary TAA within five years. Patients with early failure after primary TAA were designated as the "Failure group". Patients without early failure and who were followed up unremarkably for at least five years after primary TAA were designated as the "No failure group". Overall, 2157 TAA participants were included. During the study period, 197 patients developed failure within five years postoperatively, for an overall failure rate of 9.1%. Significant risk factors for early failure were history of chronic pulmonary disease, diabetes, peripheral vascular disease, hyperlipidemia, dementia, and alcohol abuse. A significant increase of odds ratio was found in patients with a history of dementia, chronic pulmonary disease, and diabetes. Surgical indications and preoperative patient counseling should consider these factors.

Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery

BACKGROUND

We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR).

METHODS

We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected.

RESULTS

The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001).

CONCLUSION

While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

BACKGROUND

Postoperative emergency department (ED) visits following suboccipital decompression in Chiari malformation type I (CM-1) patients are not well described. We sought to evaluate the magnitude, etiology, and significance of postoperative ED service utilization in adult CM-1 patients at a tertiary referral center.

METHODS

A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS).

RESULTS

In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a postoperative ED visit (P = 0.023). The occurrence of a postoperative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted odds ratio of CCOS ≥13 = 0.35, P = 0.021; adjusted odds ratio of CCOS ≥14 = 0.38, P = 0.016).

CONCLUSIONS

Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of postoperative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of postoperative ED service utilization are warranted.

Traditional Risk Factors and Logistic Regression Failed to Reliably Predict a "Bundle Buster" After Total Joint Arthroplasty

BACKGROUND

The purpose of this study was to determine if we could identify patient factors that were predictive of Medicare and privately insured patients being "high-cost."

METHODS

Ninety-day episode-of-care insurance company payments along with collected demographics, comorbidities, and readmissions were reviewed for a consecutive series of primary total joint arthroplasty patients from 2015 to 2016 at our institution. High-cost patients were identified by determining those patients above the cutoff, where the cost data became demonstrably nonparametric and both univariate analysis and logistical regressions were performed to identify risk factors that lead to increased costs. Receiver operator curves were created to determine the predictive nature of these risk factors.

RESULTS

Univariate analysis showed that high-cost privately insured patients were significantly older, more likely to be readmitted and less likely to be discharged to home (P < .001) whereas high-cost Medicare total knee/total hip arthroplasty patients were more likely to have many of the comorbidities analyzed. Logistical regression did not find any predictive factors for privately insured patients and found that diabetes (OR 1.47 and 1.75, respectively), congestive heart failure (OR 1.94 and 3.46, respectively), cerebrovascular event (OR 2.20 and 2.20, respectively) and rheumatic disease (OR 1.78 and 1.78, respectively) were all predictive of being a high-cost Medicare patient.

CONCLUSION

Traditional risk factors for postoperative complications are not reliably associated with increased patient costs after total hip and total knee arthroplasty. Furthermore, the risk factors associated with increased costs vary greatly between privately insured and Medicare-insured patients. Further investigation is necessary to identify cost drivers in this patient subset to preventive higher costs.

Patients at Risk for Exceeding CJR Cost Targets After Total Ankle Arthroplasty

BACKGROUND

The Comprehensive Care for Joint Replacement (CJR) model includes total ankle arthroplasty (TAA), under which a target reimbursement is established. Whether this reimbursement is sufficient to cover average cost remains unknown. We hypothesized that a substantial number of TAAs still exceed cost targets, and that risk factors associated with exceeding the target cost could be identified preoperatively.

METHODS

Two hundred two primary TAAs performed at a single tertiary referral center under the CJR model from June 2013 to May 2017 were retrospectively reviewed. Patient demographics, comorbidities, outcomes, and costs were extracted from the electronic medical record using a validated structured query language (SQL) algorithm. A comparison cohort of 2084 CJR total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases performed during the same period was also reviewed.

RESULTS

Twenty TAAs (10%) exceeded the target cost of care, significantly fewer than CJR THAs/TKAs (29%) performed during the same period (P < .0001). These patients did not differ significantly in age, sex, body mass index, number of Elixhauser comorbidities, or the American Society of Anesthesiologists score. The average cost for these patients was $17 338 higher than those who did not exceed the target cost, and they were less likely to be married or have a partner (45% vs 79%, P = .001). Non-Caucasian status also reached significance (P < .0001). Those exceeding the target cost had a significantly longer length of stay (2.6 vs 1.5 days, P < .0001) and were more likely to be discharged to either skilled nursing or a rehabilitation facility (60% vs 1%, P < .0001).

CONCLUSION

Even high-volume TAA centers still exceed target costs in up to 10% of cases, with length of stay, discharge location, and readmissions driving many of these events. Potential risk factors for excess cost include marital/partner status and non-Caucasian ethnicity, but further work is needed to clarify their effects and whether other risk factors exist.

LEVEL OF EVIDENCE

Level III, comparative study.