Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population.

BACKGROUND: Total joint arthroplasty is the most common elective orthopedic procedure in the Veterans Affairs hospital system. In 2019, physical medicine and rehabilitation began screening patients before surgery to select candidates for direct transfer to acute rehab after surgery. The primary outcome of this study was to demonstrate that the accelerated program was successful in decreasing inpatient costs and length of stay (LOS). The secondary outcome was to show that there was no increase in complication, reoperation, and readmission rates. METHODS: A retrospective review of total joint arthroplasty patients was conducted with three cohorts: 1) control (n = 193), 2) transfer to rehab orders on postop day #1 (n = 178), and 3) direct transfers to rehab (n = 173). To assess for demographic disparities between cohorts, multiple analysis of variance tests followed by a Bonferroni P-value correction were used. Differences between test groups regarding primary outcomes were assessed with analysis of variance tests followed by pairwise t-tests with Bonferroni P-value corrections. RESULTS: There were no significant differences between the cohort demographics or comorbidities. The mean total LOS decreased from 7.0 days in the first cohort, to 6.9 in the second, and 6.0 in the third (P = .00034). The mean decrease in cost per patient was $14,006 between cohorts 1 and 3, equating to over $5.6 million in savings annually. There was no significant change in preintervention and postintervention short-term complications (P = .295). CONCLUSIONS: Significant cost savings and decrease in total LOS was observed. In the current health care climate focused on value-based care, a similar intervention could be applied nationwide to improve Veterans Affair services.

Analysis of Preoperative Screening Criteria for Total Joint Arthroplasty in a Veteran Population.

BACKGROUND: This study describes the experience of patients who initially failed total joint arthroplasty preoperative screening criteria but were subsequently optimized and underwent surgery. METHODS: Time to optimization from the patients' initial clinic visit was recorded. Following surgery, patients' body mass index and lab work were tracked to determine whether they "relapsed" to their preoptimized state. Descriptive statistics determined (1) the length of time to meet screening criteria and (2) which screening criteria took the longest to optimize. RESULTS: Only 11 of 84 patients (13%) required greater than 1 year to meet criteria. Most patients (76%) "relapsed" to their previous nonqualifying status after surgery; however, this reversion did not contribute significantly to an increased rate of complication in short-term follow-up (P = .4298). CONCLUSION: Patients in this study were able to achieve preoperative screening criteria for total joint arthroplasty in less than 1 year. Relapsing after surgery does not appear to adversely affect clinical outcomes.

Early Experience and Results Using Patient-Reported Outcomes Measurement Information System Scores in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Our study determined if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores could predict achieving minimum clinically important differences (MCIDs) in postoperative PROMIS scores after primary total hip and knee arthroplasty. METHODS: Ninety-three patients were administered the PROMIS Depression, Pain Interference, and Physical Function domains at their preoperative appointment and 6-week follow-up visit. MCIDs were drawn from existing literature for the PROMIS domains. RESULTS: The MCID was achieved in 74% of patients for Pain Interference, 34% for Physical Function, and 24% for Depression. Our model could predict with 90% specificity which patients would meet MCID if their preop PROMIS Pain score was above 38, Physical Function score less than 19, or Depression score above 22. CONCLUSION: Preoperative PROMIS Pain Interference, Physical Function, and Depression scores can predict achieving MCID in postoperative PROMIS scores.

Innovative use of chemodenervation in the treatment of postoperative genital hyperhidrosis-like symptoms.

Postoperative complications present in many forms and can cause great morbidity and even mortality in patients who experience them. Frey syndrome is an example of a postoperative complication in which aberrant nerve regeneration following parotidectomy leads to hyperhidrosis induced by gustatory stimuli. We present a unique but similar case of aberrant nerve regeneration and resulting hypersecretion that emerged 6-7 months following perineoplasty and labial reduction for lichen sclerosus in a 53-year-old woman. An exhaustive investigation ruled out genitourinary causes of her symptoms. Pads, tampons, and surgical procedures provided no relief. We propose that the mechanism of her excessive watery secretions is similar to that which causes Frey syndrome: iatrogenic damage to nerves that aberrantly regenerate to innervate local structures involved in secretory control. The parallels between our patient's condition and Frey syndrome are evident in the duration between surgery and onset of symptoms and the response to treatment with onabotulinum toxin, highlighting a shared cholinergic pathway. Onabotulinum injections are well tolerated by patients with localized hyperhidrosis and symptom control typically lasts several months. In this manuscript we present a novel mode of delivery of onabotulinum toxin topically to a mucosal region. With these treatments, the patient's hyperhidrosis-like symptoms remain well controlled for 3-4 months, at which point she returns to clinic for treatment. The patient did not experience symptomatic relief until this unique treatment plan was initiated. Her case illustrates the need for further understanding of recalcitrant postoperative complications involving local structures controlling liquid secretion, such as sweat glands and vascular plexuses.

Treatment of molluscum contagiosum in adult, pediatric, and immunodeficient populations.

BACKGROUND: Molluscum contagiosum is a viral infection of the skin that is widely considered to be a self-resolving disease that can be treated with benign neglect. However, the clinical reality is that the disease can vary widely by anatomic site and by recalcitrance to treatment and remains a significant cause of morbidity worldwide. OBJECTIVE: The purpose of this review was to compile an updated resource for clinicians that addresses the management of the broad spectrum of molluscum cases that may be encountered. METHODS: A comprehensive PubMed search was performed to identify publications on the treatment of molluscum infection, including presentations that may be rare or difficult. RESULTS: The specific clinical scenario of molluscum must be considered when selecting the optimal therapy because certain treatments can be more effective for specific patient subpopulations. CONCLUSION: Further attention must be directed toward standardizing treatment for molluscum infection based on patient age and immune status.