A Remote Physical Therapy Program Demonstrates Similar Outcomes Compared to In-Person, Supervised Physical Therapy After Same-Day Discharge Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: A growing number of total knee arthroplasty (TKA) patients are candidates for same-day discharge (SDD). Previous research has shown that internet-based remote physical therapy (RPT) can produce equivalent outcomes to supervised outpatient physical therapy (OPT) after TKA. We sought to compare outcomes between RPT and OPT in patients undergoing SDD TKA using an electronic remote perioperative management (ERPM) program. METHODS: Patients undergoing SDD TKA were enrolled in an ERPM program and randomized to ERPM + RPT or ERPM + OPT. Preoperative and 6-week functional assessments included knee range of motion, timed up and go, and 4-meter gait speed. Numerical Rating Scale pain scores were evaluated preoperatively, at 6 and 12 weeks, and satisfaction was assessed at 6, 12, and 52 weeks postoperatively. Participants completed the Veterans Rand 12 Item Health Survey and Knee Injury and Osteoarthritis Outcome Score preoperatively and at 6, 12, and 52 weeks postoperatively. OPT utilization was collected 90 days postoperatively. RESULTS: Of 197 initially randomized patients, 76 remained in the ERPM + RPT group and 95 in the ERPM + OPT group after withdrawals and crossovers. Baseline characteristics showed no differences between the 2 groups. No clinically relevant differences were observed in knee range of motion, Numerical Rating Scale pain, patient-reported outcomes, functional assessments, or satisfaction at any follow-up time. Participants in the ERPM + OPT group attended an average of 11.57 physical therapy sessions, incurring a total cost of $462.8 and 133 minutes of travel. Conversely, the ERPM + RPT group experienced no expenses or travel time. CONCLUSIONS: Patients in the ERPM + RPT group had similar outcomes, lower costs, and saved time compared to patients in the ERPM + OPT group after SDD TKA. Further analysis is needed to determine predictive indicators for crossovers.

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty.

BACKGROUND: Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively. METHODS: We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks. RESULTS: All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003). CONCLUSIONS: This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study.

BACKGROUND: As the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes. METHODS: In this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression. RESULTS: In total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001). CONCLUSION: THA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized, Single-Blind, Controlled Trial.

BACKGROUND: The direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy. METHODS: This single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively. RESULTS: Ninety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively. CONCLUSION: This study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule's role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty.

BACKGROUND: Depression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA. METHODS: This is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications. RESULTS: In total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001). CONCLUSIONS: NOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient.

BACKGROUND: Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications. METHODS: This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses. RESULTS: Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001). CONCLUSION: Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Preoperative Analgesia, Complications, and Resource Utilization After Total Hip Arthroplasty: Tramadol Is Associated With Less Risk Than Other Preoperative Opioid Medications.

BACKGROUND: Preoperative opioid use is known to be detrimental to outcomes after total hip arthroplasty (THA). This is concerning as multiple societies recommend tramadol for the management of arthritis. The purpose of this study was to determine if tramadol is associated with postoperative complications, increased resource utilization, and revision when compared with patients receiving nontramadol opioids (NTOs) and those who are opioid naive (ON). METHODS: This is a retrospective cohort study using the Truven MarketScan databases (Truven Health, Ann Arbor, MI). Adult patients undergoing primary THA were identified and divided into 4 cohorts based on preoperative opioid medications (ie, ON, tramadol-only [TO], or NTOs; ±tramadol). Demographics, comorbidities, and 90-day complications were collected and compared between cohorts. Revision rates were compared at 3 years. Univariate and multivariate analyses were performed. Finally, preoperative prescription patterns were trended during the study period. RESULTS: About 198,357 patients, including 18,694 TO and 106,768 ON, were identified. Compared with ON, TO patients had similar rates of complications and revision surgery (P > .05) but had slightly higher emergency department visits (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 1.01-1.12; P = .027), readmissions (OR, 1.16; 95% CI, 1.09-1.22; P < .001), and nonhome discharges (OR, 1.07; 95% CI, 1.02-1.12; P = .010). TO patients had significantly lower odds of incurring most examined complications, including revision surgery, when compared with NTO (P < .05). From 2009 to 2018, the proportion of patients prescribed preoperative opioids decreased. CONCLUSION: Preoperative TO is associated with less postoperative risk than NTO use and is similar to opioid naivety. Fortunately, the number of patients receiving preoperative NTOs appears to be decreasing. Our results support tramadol as an appropriate pre-THA analgesic.

Anterior Revision Hip Arthroplasty is Associated With Higher Wound Complications but Fewer Dislocations Compared to Posterior Revision Hip Surgery.

BACKGROUND: Wound complication after primary direct anterior (DAA) hip arthroplasty has been reported in the literature but there has been no comparison regarding revision anterior vs revision posterior (PA) hip arthroplasty. The authors hypothesize that anterior approach revision surgery may have increased wound complications compared with posterior hip revisions and also report on secondary outcome metrics. METHODS: Ninety-nine DAA and 191 PA revisions were included for analysis. Preoperative demographic characteristics, indication for revision, operative details, type of revision performed, components utilized, and postoperative complications were compared between DAA and PA groups including multivariate analysis. RESULTS: The DAA cohort demonstrated an increased risk of superficial wound complications (7.1% vs 0.5%, P = .003) and a decreased dislocation rate (2.0% vs 13.1%, P = .002). There was a trend toward increased overall complications in the PA group (OR 1.71, P = .078). CONCLUSION: Revision DAA THA is associated with an increased risk of superficial wound complications, but may impart a decreased dislocation rate.

Extraction Techniques for Well-fixed, Infected Hip Arthroplasty Implants.

Removal of well-fixed total hip arthroplasty components is a fundamental necessity to cure chronic prosthetic hip joint infection. However, the benefits of infection eradication must be weighed against the potential morbidity associated with implant removal. Preoperative identification of implant type, knowledge of its design characteristics, availability of specialized instrumentation and knowledge of specific surgical techniques are key elements of success. With proper preoperative planning and surgical technique, removal of well-fixed total hip arthroplasty components can be accomplished safely and can provide improvements in quality of life for patients suffering from the symptoms associated with prosthetic hip joint infection. (Journal of Surgical Orthopaedic Advances 30(4):235-242, 2021).

Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study.

Balancing postoperative analgesia with minimizing opioid consumption remains a challenge. We aim to document trends in opioid consumption for patients undergoing total hip arthroplasty (THA) and hypothesize that preoperative patient education will decrease postoperative opioid consumption. This is a prospective study of patients undergoing elective primary THA. Preoperatively, patients completed a survey regarding opioid-use history, surgical history, and pain tolerance. Patients were randomized to receive preoperative education on opioid use or no formal education. Six weeks postoperatively, patients completed a questionnaire regarding opioid use, disposal, and pain control. Ninety-five patients were included. Preoperative education was not associated with taking fewer narcotic medications (p = 0.790) and did not significantly alter disposal practices (p = 0.255). Depression was correlated with increased opioid use (mean difference 24 tabs, p = 0.001) and linked to longer duration of opioid use postoperatively (20.3 +/- 15.6 versus 7.2 +/- 7.3 days, p < 0.001). History of prior surgical procedure was associated with fewer narcotics taken (mean difference 26 tabs, p = 0.01). Depression is correlated with increased opioid use. Preoperative education did not affect opioid use or disposal frequency. (Journal of Surgical Orthopaedic Advances 30(3):144-149, 2021).

Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database.

BACKGROUND: The incidence of revision THA continues to increase and there is a need to identify risk factors contributing to postoperative complications. Anesthesia type has been shown to be associated with complication rates in patients who undergo primary THA, but it is not clear whether the same is true among patients undergoing revision THA. QUESTIONS/PURPOSES: (1) After controlling for confounding variables, in the setting of a large-database analysis, is spinal anesthesia associated with a lower risk of death, readmission, reoperation, postoperative transfusion, thromboembolic events, surgical site infection (SSI), and re-intubation among patients undergoing revision THA? METHODS: The American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing aseptic, revision THA with either spinal or general anesthesia. Coarsened exact matching was used to match patients based on several baseline characteristics, including age, sex, body mass index, surgery type (Current Procedural Terminology code), and the modified Frailty Index score. Coarsened exact matching is a statistical method of exact matching that matches on chosen characteristics, in which continuous variables may be temporarily coarsened (such as, into discrete categorical variables) to facilitate matching. This method is an alternate to and requires less estimation than traditional propensity score matching. Then, using a model controlling for baseline patient characteristics and operative time, we performed multivariate logistic and linear regression analyses of matched cohorts to examine differences in mortality, readmission, reoperation, thromboembolic events, transfusion, SSI, and re-intubation. RESULTS: After statistical matching and controlling for baseline demographic variables, surgery type (one- or two-component revision), surgical time and modified Frailty Index we found that patients receiving general anesthesia had higher odds of mortality (OR 3.72 [95% CI 1.31 to 10.50]; p = 0.013), readmission (OR 1.49 [95% CI 1.24 to 1.80]; p < 0.001), reoperation (OR 1.40 [95% CI 1.13 to 1.73]; p = 0.002), thromboembolic events (OR 2.57 [95% CI 1.37 to 4.84]; p = 0.003), SSI (OR 1.32 [95% CI 1.01 to 1.72]; p = 0.046), postoperative transfusion (OR 1.57 [95%CI 1.39 to 1.78]; p < 0.001) and unplanned intubation or failure to wean off intubation (OR 5.95 [95% CI 1.43 to 24.72]; p = 0.014). CONCLUSIONS: In patients undergoing revision THA, spinal anesthesia is associated with a decreased risk of several complications. The current investigation suggests that, when practical (such as when long surgical times or changes to the surgical plan are not anticipated), spinal anesthesia should be considered for use during revision THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030.

BACKGROUND: As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA. METHODS: The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age. RESULTS: In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA. CONCLUSION: The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends. LEVEL OF EVIDENCE: IV.

Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients. METHODS: We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence. RESULTS: Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group. CONCLUSION: Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.

Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty.

BACKGROUND: The incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship. METHODS: This is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts. RESULTS: A total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001). CONCLUSION: Depression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.

Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty.

BACKGROUND: The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient. METHODS: This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts. RESULTS: 105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001). CONCLUSIONS: Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use.

BACKGROUND: We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events. METHODS: Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days. RESULTS: The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63). CONCLUSION: This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.

Evidence-Based Hospital Procedural Volumes as Predictors of Outcomes After Revision Hip Arthroplasty.

BACKGROUND: The aim of this study is to define the evidence-based institutional volume-outcome relationship in revision hip arthroplasty. We hypothesized that high-volume centers would be associated with superior outcomes, and that stratum-specific likelihood ratio (SSLR) analysis would delineate concrete volume thresholds for optimizing outcomes. METHODS: The Nationwide Readmission Database was queried from 2011 to 2016 for patients undergoing revision hip arthroplasty. SSLR analysis was used to determine hospital volume cutoffs specific for outcomes of interest. Volume categories were confirmed with multivariate regression. RESULTS: SSLR analysis produced distinct hospital volume cutoffs for all outcomes. Each subsequent volume threshold diminished patients' risk for adverse outcomes. Tertiles were identified for 90-day infection (≤6, 7-51, ≥52 cases per year). Quartiles were found for 90-day readmission (≤5, 6-15, 16-79, ≥80), 90-day prosthesis-related complication (≤5, 6-16, 17-65, ≥66), 90-day dislocation (≤5, 6-19, 20-79, ≥80), and non-home discharge (≤5, 6-15, 16-40, and ≥41). Quintiles were generated for extended length of stay >2 days (≤2, 3-10, 11-20, 21-30, ≥31). Heptiles were produced for medical complications within 90 days (≤2, 3-8, 9-16, 17-51, 52-89, ≥90). CONCLUSION: This is the first known study to define evidence-based thresholds for the impact of hospital volume on revision joint arthroplasty. This supports the notion that institutional volume functions as a surrogate for protocolized interdisciplinary coordination of care and surgical experience, and that high-volume centers offer enhanced outcomes for complex cases. Additional studies should investigate the potential role for incentivization of such institutions, as they offer optimal outcomes for revision hip arthroplasty.

Modifiability of Depression's Impact on Early Revision, Narcotic Usage, and Outcomes After Total Hip Arthroplasty: The Impact of Psychotherapy.

BACKGROUND: Depression is known to negatively influence functional recovery, patient satisfaction, narcotic requirements, implant survivorship, and perioperative resource utilization after total hip arthroplasty (THA). The degree to which this effect is modifiable is largely unknown, with mixed results on preoperative pharmacological intervention, and concomitant concerns over side effects. We aim to investigate the influence of psychotherapy before THA on surgical outcomes, medical complications, and resource utilization. METHODS: A retrospective chart review of Truven MarketScan Databases was performed to generate 3 cohorts: patients without depression, patients with depression who did not receive preoperative psychotherapy, and patients with depression who received psychotherapy before surgery. Outcomes of interest were resource utilization, surgical and medical complications, narcotic requirements, and 1-year and 3-year revision rates. RESULTS: On multivariate analysis, depressed patients who did not receive psychotherapy were more likely to be discharged to inpatient rehabilitation facility (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.10-1.48, P < .001) and require 2 or more postoperative narcotic prescriptions (OR 1.20, 95% CI 1.06-1.37, P = .004) than depressed patients who received psychotherapy. Patients who did not receive psychotherapy were more likely to have continued narcotic requirements within 1 year after surgery (OR 1.23, 95% CI 1.08-1.39, P < .001) and undergo revision at 1 year (OR 1.74, 95% CI 1.17-2.58, P = .006) and 3 years (OR 1.92, 95% CI 1.10-3.34, P = .021) than depressed patients who received psychotherapy. CONCLUSION: The negative influence of depression on narcotic requirements, resource utilization, and implant survivorship after THA appears to be modifiable with preoperative psychotherapy.

The Influence of Modifiable, Postoperative Patient Variables on the Length of Stay After Total Hip Arthroplasty.

BACKGROUND: Many studies have examined strategies to reduce length of stay (LOS) after total hip arthroplasty (THA), but few have focused on modifiable patient-specific information in the acute postoperative period. This study investigates the determinants of LOS after THA, with a focus on potentially modifiable factors. METHODS: A total of 1278 patients undergoing elective THA from 2012 to 2014 were extracted from our institutional data warehouse at our academic orthopedic specialty hospital. Data were collected on patient demographics, comorbidities, inpatient opioid use, hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1. The main outcome was hospital LOS. Multivariate regression analysis was performed to identify independent risk factors for LOS over 3 days. RESULTS: The average age of patients undergoing primary total hip arthroplasty in our cohort was 62.3 (standard deviation 10.7) years, and 52.7% were women. Eighty-one (6.3%) of 1278 patients had a LOS more than 3 days. Multivariate regression analysis demonstrated several statistically significant nonmodifiable and modifiable risk factors that influence LOS after THA. Nonmodifiable risk factors included nonwhite race (odds ratio [OR], 1.497), single marital status (OR, 1.724), increasing age (OR, 1.330), and increasing Charlson Comorbidity Index (OR, 1.411). Potentially modifiable risk factors included every 10 mg oral morphine equivalent consumption (1.069), every 5 postoperative hypotensive events (OR, 1.232), low hemoglobin (OR, 3.265), high glucose levels (OR, 1.887), and a high creatinine (OR, 2.874). CONCLUSION: This study identifies potentially modifiable factors that are associated with increased LOS after THA, including postoperative opioid use and hypotensive events. Efforts to control narcotic use and initiatives aimed to reduce early postoperative hypotension could aid in reducing LOS. Furthermore, attempts should be made to correct postoperative anemia, high glucose levels, and a high creatinine level when possible.

Are Patients More Satisfied With a Balanced Total Knee Arthroplasty?

BACKGROUND: Patient-reported outcome measures are increasingly recognized as an important tool in quantifying the clinical success of arthroplasty surgery. The aim of this study is to measure post-operative joint awareness and satisfaction in patients with and without a quantitatively balanced knee following primary total knee arthroplasty (TKA). METHODS: In this multi-center study, a total of 318 eligible patients were assigned to one of the 2 patient groups: sensor-guided TKA or surgeon-guided TKA. In the sensor-guided group, quantitative balancing was performed according to intercompartmental tibiofemoral load measurements measured by an instrumented tibial trial component. In contrast, for the surgeon-guided group, the knees were balanced according to the surgeons' standard manual techniques while blinding the surgeon to the sensor measurements. Patients were blinded to their allocation and filled out the validated Forgotten Joint Score and 2011 Knee Society Satisfaction questionnaires at 6 weeks and 6 months. For the purposes of this study, the subjects were pooled and stratified by their state of soft tissue balance, based on the mediolateral load differential through the range of motion. RESULTS: In the surgeon-guided group, approximately 50% of the cases yielded a quantitatively balanced knee. Significantly more balanced knees were observed in the sensor-guided group (84.0%). More importantly, for both outcome measures, the balanced group of patients reported significantly better outcomes scores. CONCLUSION: This demonstrates that using sensor feedback during knee arthroplasty surgery results in a more reproducible procedure, resulting in a higher percentage of balanced patients who in turn demonstrate superior clinical outcomes compared to unbalanced patients.