The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols.

BACKGROUND: Compared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol. METHODS: This is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA. RESULTS: Patients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034). CONCLUSION: NA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty.

BACKGROUND: Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program. METHODS: A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status. RESULTS: In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m2, P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent. CONCLUSION: OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

The Effect of Psychiatric Diagnosis and Psychotropic Medication on Outcomes Following Total Hip and Total Knee Arthroplasty.

BACKGROUND: Nearly 20% of the US adult population lives with mental illness, and less than 50% of these receive treatment. Preoperative mental health may affect postoperative outcomes in patients undergoing total joint arthroplasty (TJA), yet is rarely addressed; poor outcomes increase the cost of care and burden on the healthcare system. This study examines the influence of patients with psychiatric diagnosis (PD) and taking psychotropic medication (PM) on emergency room visits, readmissions, and discharge disposition following TJA. METHODS: Single institution retrospective analysis of a consecutive series of 3020 primary TJA performed between January 2017 and June 2018. Chi-squared, t-tests, and analysis of variance were used to quantify differences between groups. RESULTS: Nine hundred seventy-six (32.3%) patients had a PD, most had depression (10.1%), anxiety (8.6%), or both (8.4%); 808 (26.8%) patients were on PM. Patients with PD were more likely to experience emergency room visits (6.3% vs 10.0%, P = .034) and skilled nursing facility discharge (11.6% vs 17.9%, P = .005). Patients taking PM were more likely to experience skilled nursing facility discharge (12.4 vs 17.1, P = .047); those taking >2 PM had the highest rate (21.6%). CONCLUSION: Patients with PD on or off PM may experience increased healthcare utilization in the postoperative period. Increased patient education and support may reduce these discrepancies. PD is not a deterrent for TJA, but targeted interventions should be developed to provide additional support where needed and avoid unnecessary utilization of resources.

Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty.

BACKGROUND: Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA). METHODS: Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor. RESULTS: In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002). CONCLUSION: AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.

Reducing Length of Stay Does Not Increase Emergency Room Visits or Readmissions in Patients Undergoing Primary Hip and Knee Arthroplasties.

BACKGROUND: Total hip and total knee arthroplasty (total joint arthroplasty [TJA]) are 2 of the most common elective surgeries. Identifying which patients are at highest risk for emergency room (ER) visits or readmissions within 90 days of surgery and the reasons for return are crucial to formulate ways to decrease these visits and improve patient outcomes. METHODS: This is a retrospective review of a consecutive series of 7466 unilateral primary TJA performed from July 2013 to June 2017; any patients who had an ER visit or readmission in the first 90 days after surgery were identified, and a detailed chart review was performed. Patients discharged home or to rehab were analyzed separately. RESULTS: Three hundred thirty-six (4.5%) patients had 380 ER visits and 250 (3.3%) patients had 291 readmissions in the first 90 days after TJA. Patients returning to the ER were equivalent to those who did not. Patients who went to a rehab facility on discharge were significantly more likely to be readmitted (P = .000). Patients who were readmitted had a higher American Society of Anesthesiologists score (P = .000). Length of stay decreased over the study period from 2.66 days to 1.63 days, while the number of unplanned interventions remained steady. Pain and swelling was the most common reason for return for ER visits (33.2%) and readmissions (14.1%). CONCLUSION: The overall number of unplanned interventions after TJA in this population was low and remained consistent over time despite decreasing length of stay. Patients who went to rehab were more likely to experience readmission. The majority of unplanned interventions occurred in the first 4 weeks after surgery.

Evaluation of the Learning Curve When Transitioning From Posterolateral to Direct Anterior Hip Arthroplasty: A Consecutive Series of 1000 Cases.

BACKGROUND: The direct anterior approach (DAA) for primary hip replacement has been gaining more attention and widespread use in recent years. There are a number of published studies evaluating the learning curve when a surgeon changes technique; these studies typically look at complications during the initial cases. This study examines procedure and total operating room (OR) time along with all complications for a surgeon transitioning from the posterolateral approach (PA) to DAA. METHODS: A retrospective review of a single surgeon series of 1000 initial DAA procedures. Total OR time, procedure time, and complications were collected and analyzed. One-way analysis of variance and post hoc least significant difference tests were used for statistical analysis. RESULTS: There was an initial increase in both procedure and OR times compared with the mature PA, by 34% and 30%, respectively. The procedure time became statistically equivalent to the mature PA time after the 400th DAA case, and significantly shorter after the 850th case. The total OR time became statistically equivalent after the 900th DAA case. There were 18 early (<90 days) and 18 late reoperations performed in this series with a nonsignificant trend toward femoral complications occurring early in the series. Minimum follow-up time was 2 years. CONCLUSION: There was an initial increase in both total OR time and procedure time when an experienced surgeon introduced the DAA. By the end of the series, procedure time was significantly shorter and total OR time was equivalent. Complications overall were low and femoral complications decreased with time.

Functional Outcomes and Accuracy of Patient-Specific Instruments for Total Knee Arthroplasty.

BACKGROUND: Patient-specific instruments (PSIs) were developed to improve mechanical axis alignment for patients undergoing total knee arthroplasty (TKA) as neutral alignment (180°) is a predictor of long-term success. This study examines alignment accuracy and functional outcomes of PSI as compared with standard instruments (SIs). METHODS: We retrospectively reviewed a consecutive series of TKA procedures using PSI. A total of 85 PSI procedures were identified, and these were compared with a matched cohort of 85 TKAs using SI. Intraoperative decision-making, estimated blood loss, efficiency, Knee Society Scores, and postoperative radiographs were evaluated. RESULTS: One hundred and seventy patients with comparable patient demographics were reviewed. Eighty-one percent of the PSI procedures were within target (180 ± 3°) mechanical alignment, while the SI group had 70% of cases within the target plane ( P = .132). Mean target alignment (2.0° PSI vs 2.2° SI, P = .477) was similar between groups. Twenty-seven percent of patients in the PSI group had surgeon-directed intraoperative recuts to improve the perceived coronal alignment. The change in hematocrit was reduced in the PSI group (8.89 vs 7.21, P = .000). Procedure time and total operating room time were equivalent. Knee Society Scores did not differ between groups at 6 months or at 1 year. CONCLUSION: Patient-specific instrumentation decreased change in hematocrit, though coronal alignment and efficiency were equivalent between groups. Surgeons must evaluate cuts intraoperatively to confirm alignment. Functional outcomes are equivalent for PSI and SI groups.

Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure.

BACKGROUND: This study aimed to examine the major reasons for total hip arthroplasty (THA) failure and temporal patterns in THA revisions. METHODS: A retrospective chart review was conducted on 535 revisions performed on 444 THAs from January 2010 to May 2019 at our institution. RESULTS: The average time to revision THA was 8.51 ± 8.38 years, with 136 cases (30.9%) occurring within 2 years after primary THA. The major mechanisms of failure that resulted in revision surgery were mechanical failure (162, 36.5%), metallosis (95, 21.4%), dislocation or instability (65, 14.6%), periprosthetic fracture (46, 10.4%), infection (44, 9.9%), hematoma or poor wound healing (15, 3.4%), and pain or other (17, 3.8%). CONCLUSION: Based on our institutional experience over the past decade, mechanical failure without dislocation, metallosis, dislocation, periprosthetic fracture, and infection are typical reasons patients present for primary THA revision. Revisions within 2 years after primary THA are more likely to be the result of infection and periprosthetic fracture. Mechanical failure is the most common reason for revision THA overall, and mechanical failure and metallosis are more likely to be the reason revision is necessary 2 or more years after primary THA.

Simultaneous combined retroperitoneal and posterior hip approach for the treatment of iliopsoas abscess with extension to a metal-on-metal prosthetic hip joint.

Iliopsoas abscess is an uncommon entity that has only rarely been associated with periprosthetic hip infection; to our knowledge, these are the first reported cases in patients with metal-on-metal (MoM) hip arthroplasty. We report 2 cases of iliopsoas abscess and concomitant periprosthetic hip infection in patients with a history of MoM hip arthroplasty. Case 1 presented with an acute infection 18 months after revision total hip arthroplasty (THA) for instability and adverse local tissue reaction after MoM THA. Case 2 presented with an acute infection in a previously well-functioning MoM THA. Both cases were treated with combined hip and retroperitoneal approaches and required more aggressive and longer treatment than is typical for periprosthetic infection, but ultimately resulted in successful revision THAs. We outline the treatment of these 2 patients and review the previously reported literature.

The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty.

BACKGROUND: Penicillin (PCN) allergy is reported in 10% to 20% of the population; studies show that only 1% to 3% of patients have a true allergy. Most patients reporting a PCN allergy receive second-line antibiotic prophylaxis preoperatively, which raises concerns about antimicrobial efficacy. Studies also suggest that second-line antibiotics may increase the rate of surgical site infection (SSI). In this study we aim to analyze the effect of PCN allergy on antibiotic type prescribed and SSI in our total joint arthroplasty population. METHODS: A retrospective review of 4,903 primary total hip and total knee arthroplasty performed from January 2015 to June 2017 in a single institution. A detailed chart review was performed to identify reported reactions and antibiotic prescribed. RESULTS: Seven hundred ninety-six patients (16.2%) reported a PCN allergy; the reactions were classified into three tiers. Six hundred fifteen patients (12.5%) reported an IgE-mediated allergy, hypersensitivity, or a possible allergy; 89 (1.8%) reported an adverse effect; and 92 (1.9%) had an unknown reaction. Patients reporting a PCN allergy were less likely to receive cefazolin (94.9 versus 6.9%; P < 0.001) and more likely to receive clindamycin (1.1 versus 80.7%; P < 0.001) or vancomycin (4.0 versus 12.4%; P < 0.001). There was no difference in infection rate by reported PCN allergy (0.6 versus 0.4%; P = 0.473) or antibiotic prescribed (0.5 versus 0.6%; P = 0.4817). CONCLUSION: No patient with a PCN allergy and given cefazolin experienced a reaction; based on reported reactions, most patients with a PCN allergy can safely receive first-line antibiotic therapy. In this population, PCN allergy and second-line antibiotic therapy did not influence the rate of SSI.