PT Achievement in Public Hospitals and Its Effect on Outcomes.

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

The Evolution of Cement Fixation in Total Knee Arthroplasty.

Aseptic loosening and infection are two of the leading causes of revision in total knee arthroplasty. While several patient-related factors can play a role in the development of these complications, there are certain modifiable surgeon factors that can help mitigate the risk. Intraoperatively, this can begin with the curing process of bone cement which is broken down into four different stages: mixing, waiting, working, and setting. Understanding each stage of the process is beneficial in obtaining successful long-term outcomes. Developing optimal bone-cement penetration is of utmost importance in establishing a strong interface. Proper penetration of cement is dependent on multiple factors including the cement's properties along with its application to the prosthesis and bone surfaces. Combinations of different cement application techniques have yielded results with varying bone-cement interface strength. While a proper cementation technique is critical to the long-term success of a total knee replacement, other factors, such as antibiotic-loaded bone cement (ALBC), can help prevent and treat complications (such as infection). Although ALBC was not approved in North America by the Food and Drug Administration (FDA) until 2003, it was first described in 1970 and has been routinely used in revision total knee arthroplasty with reliable antibiotic elution properties and an acceptable safety profile.

Greater Rates of Acute Kidney Injury in African American Total Knee Arthroplasty Patients.

BACKGROUND: This retrospective study compared the change in serum creatinine between African American and Caucasian total knee arthroplasty (TKA) patients. The authors hypothesized that African Americans would demonstrate significantly greater change, and that a significantly greater proportion would demonstrate creatinine changes consistent with acute kidney injury (AKI). METHODS: Primary TKAs performed at a single institution between July 2011 and June 2016 were identified: 1035 primary TKAs met inclusion and exclusion criteria (110 African American, 925 Caucasian, excluding Hispanic and Asian patients). None were excluded based on gender, age, body mass index, preoperative diagnosis, or comorbidities. All patients had preoperative and postoperative creatinine levels available in the electronic medical records. Each patient received the same preop and postop protocol for nonsteroidal anti-inflammatory drug use along with other drugs administered including anesthesia. All patients received 1 g of intravenous vancomycin with some patients additionally receiving 1 g of vancomycin powder administered locally at the end of surgery. All patients were controlled for fluid intake and blood loss, along with no patient receiving a transfusion or intravenous contrast. Patient demographics and preoperative/postoperative serum creatinine were recorded and then analyzed for presence of AKI (≥0.3 mg/dL). Preoperative/postoperative serum creatinine concentrations were compared between African American and Caucasian patients using 2 × 2 repeated measures analysis of variance. Prevalence of patients in each group demonstrating AKI was calculated using Fisher's exact test. RESULTS: African American patients had significantly greater serum creatinine preoperatively (1.00 ± 0.26 vs 0.90 ± 0.22, P < .001) and a significantly greater increase postoperatively (0.10 vs 0.03, P < .001). A significantly greater number of African American patients demonstrated AKI (10.9% vs 5.1%, P = .03). Furthermore, a significantly greater number of African American patients stayed in the hospital an additional 2 or more days for renal issues (2.7% vs 0.4%, P = .03). CONCLUSION: Altered renal function was significantly more common in African American TKA patients. Future studies are necessary to determine if tailoring anti-inflammatories, perioperative medications, and preoperative comorbidities reduce the risk of renal injury and/or a longer hospital stay for this subset of patients.

The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty.

BACKGROUND: The purpose of this systematic review is to compare deep prosthetic joint infections (PJIs) between total knee arthroplasty (TKA) patients treated with either antibiotic-loaded bone cement (ALBC) or plain bone cement, and to explore the potential cost implications of commonly used bone cement regimens. We hypothesized that ALBC would not substantially reduce PJIs and would thereby present an unnecessary cost to the healthcare system. METHODS: Using the PRISMA guidelines, we reviewed articles through May 2017 involving primary TKA patients with both ALBC cohort and plain bone cement cohort. A meta-analysis was performed comparing the prevalence of deep infections between cohorts. A cost comparison for a hypothetical setting with an annual volume of 1000 TKAs was performed to compare 3 commonly used cement regimens: 2 bags of ALBC used during each case, 1 bag of ALBC with 1 bag of plain cement, and 2 bags of plain cement. Pricing at our institution is $215/bag for commercial ALBC and $60/bag for plain cement. RESULTS: Eight articles were included with a total of 34,664 patients. ALBC did not reduce the PJI (ALBC = 93/8189, 1.1% vs plain = 251/26,475, 0.9%; P = .09). The estimated costs for the 3 bone cement regimens per 1000 primary TKAs were as follows: 2 bags of ALBC = $430,000/y, 1 bag of ALBC +1 bag of plain cement = $275,000/y, and 2 bags of plain cement = $120,000/y. CONCLUSION: ALBC did not reduce the prevalence of PJI suggesting that ALBC may be an unnecessary cost to the healthcare system. Hospital systems that perform 1000 TKAs/y could save between $155,000 and $310,000/y by switching to plain cement.