Is an "Outpatient Arthroplasty Risk Assessment Score" Needed for Predicting Safe Selection of Outpatient Arthroplasty Candidates?

BACKGROUND: Total joint arthroplasty is rapidly shifting to the outpatient space. One of the challenges of same-day discharge adoption has been determining which patients are suitable candidates. Risk assessment tools have been developed, including the Outpatient Arthroplasty Risk Assessment (OARA) score. The purpose of this study was to assess its predictive utility. METHODS: A retrospective review was performed on all total joint arthroplasties performed at a single ambulatory surgery center in 2018, yielding a cohort of 1,105 patients (1,332 arthroplasties). The institution's outpatient criteria required optimization of all medical conditions; if the patient had no failing organ, they were candidates for same-day discharge. OARA scores were calculated based on preoperative histories and physical examinations. Analyses were performed on the statistical utility of the OARA score in predicting successful same-day discharge. The mean age was 59 years (range, 27-82), the mean body mass index was 33.3 kg/m2 (range, 16-66), and 51.5% were women. A total of 45% of patients had one or more major comorbidity. RESULTS: There were 81.6% of patients who had an acceptable OARA score (<60). In addition, 97% of patients who had an "unacceptable" OARA score were successfully discharged the same day. There were 23 patients who required inpatient observation; of these, 7 (30.4%) had an OARA score ≥60. CONCLUSION: The OARA score was accurate in predicting patients who successfully had same-day discharge but poor at predicting who would not. This system is time consuming and may be too restrictive on which patients are candidates for outpatient arthroplasty. Surgeons may consider a more simplified criteria for outpatient arthroplasty.

Improving Operating Room Efficiency with Single-Use Disposable Instruments for Total Knee Arthroplasty.

Many strategies have been employed to improve operating room efficiency when performing total knee arthroplasty. The goals of efficiency improvements are to decrease operative time and reduce healthcare expenses while providing patients the best quality surgical care. Single-use disposable instruments are one technique to accomplish efficiency. The authors describe their experience with a specific implant manufacturer's disposable single-use instruments for total knee arthroplasty and analyze the cost and time savings compared to traditional instrumentation. Single-use disposable instruments are a viable option to improve OR efficiency, decrease sterile processing burden, and ensure sterile instrumentation for total knee arthroplasty. Furthermore, cost savings can be realized based on an institution's sterile processing expenses and whether the manufacturer or facility covers the cost of the single-use instruments.

Fellow Involvement in Primary Total Knee Arthroplasty: Is There an "August Effect?"

The purpose of this study is to determine if a fellow's involvement, as well as duration of a fellow's training, impacts complications, outcomes, and survivorship in primary total knee arthroplasty (TKA). A retrospective review identified 2,790 consecutive patients (3,530 knees) who underwent primary TKA between 2003 and 2008. A 2-year minimum follow-up was available on 2,785 knees (2,195 patients). Operative data, clinical outcomes, complications, and survivorship were compared between cases with and without a fellow involved as well as comparing cases in the first quarter (Q1) of the academic year to the last three quarters (Q2-4). Mean follow-up was 9.7 years. Fellows were involved in 1,434 (41%) surgeries. Fellow cases had significantly longer tourniquet times (59.5 vs. 49 minutes, p < 0.001) and operative times (82.4 vs. 70.8 minutes, p < 0.001). Overall, there was no difference in clinical, functional, or pain outcomes between attending and fellow cases. Fellow cases during Q1 had significantly worse pain scores (p = 0.009) and clinical scores (p < 0.001). Revision rate, infection rates, and survivorship were not significantly different between fellow and attendings or during Q1 of fellowship compared with attendings. Primary TKA survivorship and complications were not affected by fellow involvement or academic quarter. An "August Effect" may be suggested for clinical and pain outcomes in the first 3 months of fellowship.

New total knee arthroplasty designs: do young patients notice?

BACKGROUND: Although the volume of total knee arthroplasties (TKAs) performed in the United States continues to increase, recent reports have shown the percentage of patients who remain "unsatisfied" is as high as 15% to 30%. Recently, several newer implant designs have been developed to potentially improve patient outcomes. QUESTIONS/PURPOSES: The purpose of this study was to determine the impact of high-flex, gender-specific, and rotating-platform TKA designs on patient satisfaction and functional outcomes. METHODS: A four-center study was designed to quantify the degree of residual symptoms and functional deficits in patients undergoing TKA with newer implant designs compared with a 10-year-old, cruciate-retaining (CR) TKA system introduced in 2003. Each contributing surgeon was fellowship-trained and specialized in joint replacement surgery. Only patients younger than 60 years old were included. Data were collected by an independent, third-party survey center blinded to the implant type, who administered questionnaires about patient satisfaction, residual symptoms, function, and pre- and postoperative activity levels using previously published survey instruments. Two hundred thirty-seven CR, 137 rotating-platform, 88 gender-specific, and 65 high-flex TKAs were included in the analysis. Differences in baseline demographic variables were accounted for using multiple logistic regression statistical analyses. RESULTS: Patients who received certain newer designs reported more residual symptoms (grinding, popping, and clicking) in the 30 days before survey administration than the group receiving a 10-year-old CR design (CR, 24% [57 of 237 patients] versus gender-specific, 36% [32 of 88 patients]; odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1-3.8; p=0.03; and rotating-platform, 43% [59 of 137 patients]; OR, 2.2; 95% CI, 1.3-3.7; p<0.001). They also reported more functional problems, including getting in and out of a chair (CR, 19% [46 of 237 patients] versus gender-specific, 37% [32 of 88 patients]; OR, 1.0; 95% CI, 1.1-3.5; p=0.001). Patients with newer TKA designs did not demonstrate any improvements in function or patient satisfaction versus those who received the 10-year-old CR design. CONCLUSIONS: When interviewed by an independent, blinded third party, the use of newer implant designs did not improve patient satisfaction and the presence of residual symptoms when compared with patients who received the 10-year-old CR design. Future studies should prospectively determine whether the purported benefits of newer implant designs improve patient-perceived outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is socioeconomic status a risk factor for stiffness after total knee arthroplasty? A multicenter case-control study.

Socioeconomic factors may play a role in the development of arthrofibrosis following total knee arthroplasty. Using manipulation following total knee arthroplasty as a surrogate for stiffness, this multicenter case-control study found that African American and young patients (<45 years of age) had twice the odds for manipulation compared with Caucasian and older-age patients.

Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty.

Recently, patient-specific approaches to total knee arthroplasty (TKA) have been introduced that utilize preoperative magnetic resonance imaging data to manufacture custom cutting jigs specific to a patient's bony anatomy. These approaches intend to provide the benefits of accurate implant alignment while overcoming some of the proposed disadvantages of current computer navigation systems. In this study, a cost and benefit assessment of implementing the patient-specific approach compared to conventional and computer-navigated TKA was conducted at a large academic medical center. Fixed and time-dependent operating room (OR) costs were determined and compared, as well as the cost for processing operative equipment and additional procedure-related expenditures. Overall, patient-specific TKA was not cost saving in this model on a per-case basis compared to conventional methods, although it was less costly overall to the institution compared to implementing intraoperative navigation. However, the patient-specific approach provides the institution with an additional 28 minutes of available OR time per intervention based on reduction in preparation and operative times compared to conventional methods and an additional 67 minutes compared to computer navigation based on this model. This time savings is likely to provide a greater economic impact to the health care system than implant-related cost savings.

Prevalence and management of obstructive sleep apnea in patients undergoing total joint arthroplasty.

Obstructive sleep apnea (OSA) may be a risk factor for complications after total joint arthroplasty (TJA). We sought to determine the prevalence of OSA in patients undergoing TJA, and the safety and effectiveness of intrathecal narcotic (IN) in these patients. We retrospectively reviewed 1255 consecutive patients undergoing 1463 TJA at one hospital. All patients underwent routine screening for OSA and IN anesthesia, with 109 patients (134 TJA) identified with OSA (8.7%). Compared with 127 randomly selected patients (141 TJA) without OSA, OSA patients were significantly heavier and had higher American Society of Anesthesiologists scores, more comorbidities, longer length of stay, more transient hypoxia, more transfusions, and more medical variances. Despite more minor variances, with appropriate screening and management, OSA patients did not have a higher rate of significant or major complications. Length of stay, although longer, was only 2.3 days in OSA patients, demonstrating the safety and efficacy of IN anesthesia in these patients.

A short stem solution: through small portals.

While short stem design in total hip arthroplasty (THA) is not a new concept, interest has surged with the increasing popularity of less invasive techniques. Given the success of traditional stems, why consider short stems? Several reasons exist. If the goal of the tapered stem is to load preferentially proximally, achieve tight fit, and deliver stresses into proximal bone, do we need a stem at all? While long stems may prevent varus malalignment, varus malalignment of tapers does not impair results. Short stems are easier to insert, especially when using an anterior approach. Femoral preparation is accomplished with straightforward broaching without reamers. Short stems are bone conserving, violating less bone stock and providing more favorable conditions should revision be required. As with any novel device, longer follow-up is needed to fully assess shortened tapered stems. However, our early results in 640 primary THAs at up to 38 months are promising. Usually 1 or 2 diameter sizes larger are required with the short vs standard length version of the same tapered design. Be aggressive with sizing, pushing to the largest possible. Use the broach like a rasp. Drive the component in valgus during insertion. Upon seating, do a trial reduction using the shortest available neck length. The component generally sits slightly prouder than the broach and may require additional effort to seat completely.

Simultaneous vs staged cementless bilateral total hip arthroplasty: perioperative risk comparison.

Simultaneous vs staged bilateral total hip arthroplasty (THA) continues to evoke controversy, with perioperative complications representing the most significant issue. Previous authors have reported significant cost savings by performing bilateral THA simultaneously, but have failed to address issues of surgeon and hospital reimbursement. This study compares 277 consecutive patients undergoing either simultaneous (334 THAs) or staged bilateral cementless THA (220 THAs) in lateral decubitus position using a single cementless stem design, with emphasis on perioperative complications and reimbursement to surgeon and hospital. There were significantly more inpatient complications and adverse events in patients undergoing simultaneous bilateral THA in the lateral decubitus position, significantly higher transfusion requirement, and more patients failing to reach physical therapy goals during admission requiring more transfers to rehabilitation facilities. Need for subsequent hip surgery was also significantly higher in simultaneous bilateral patients. In addition to these negative results, the hospital system realized a 28% reduction and the surgeon suffered a 15% reduction in potential reimbursement.