Utilization, Complications, and Costs of Inpatient versus Outpatient Total Elbow Arthroplasty.

BACKGROUND: Although total hip and knee arthroplasty have largely moved to the outpatient setting, total elbow arthroplasty (TEA) remains a predominantly inpatient procedure. Currently, evidence on the safety and potential cost savings of outpatient TEA is limited. Therefore, we aimed to compare the costs and complications associated with performing TEA in the inpatient versus outpatient setting. METHODS: We identified patients who received elective TEA using the Truven Health MarketScan database. Outcomes of interest were 90-day complication rate, readmission rate, and procedure costs in the inpatient and outpatient settings. We used propensity score matching and logistic regression analysis to assess how patient comorbidities and surgical setting influenced complications and readmission rates. The median cost per patient was compared using the Mann-Whitney U test. RESULTS: We identified 307 outpatient and 414 inpatient TEA procedures over a 9-year period. Elixhauser comorbidity scores were higher for the inpatient cohort. The incidence of surgical complications was significantly higher in the inpatient than the outpatient cohort (27% vs 9%). The odds of 90-day readmissions were similar in the 2 groups (37% vs 25%). In terms of cost, the median inpatient TEA was more expensive than outpatient TEA ($26 817 vs $18 412). However, the median cost for occupational therapy within 90 days of surgery was higher for outpatient TEA patients ($687 vs $571). CONCLUSIONS: The results of this study demonstrate that surgeons can consider a transition toward outpatient TEA for patients without significant comorbidities, as this will substantially reduce health care costs.

Evaluation of a Simplified Risk Stratification Twice-Daily Aspirin Protocol for Venous Thromboembolism Prophylaxis After Total Joint Replacement.

OBJECTIVE: To determine using a simplified risk-stratified protocol to select candidates for aspirin therapy have similar death and postoperative complications as universal warfarin therapy in patients undergoing total joint replacement (TJR). METHODS: Retrospective cohort study comparing 30-day postoperative outcomes 6 months before and after the implementation of the aspirin protocol (January 1, 2015) in patients undergoing TJR. The control group was comprised of patients using warfarin for VTE prophylaxis. The protocol group included patients who used aspirin 325 mg twice-daily or warfarin if deemed high thrombotic risk or aspirin intolerant by the criteria set forth by the aspirin protocol. RESULTS: This study included 449 patients. No difference was found in the rates of 30-day postoperative bleeding, VTE, death, composite end point of VTE and death, and length of stay between the control and the protocol groups (all P > .05). Thirty-day postoperative surgical site infections (SSIs; 5.8% vs 1.2%; P = .02) and return to operative room (OR; 3.9% vs 0.4%; P = .03) were less frequent in the protocol group. CONCLUSION: A simplified risk-stratified protocol used to choose patients for aspirin 325 mg twice-daily therapy is safe and effective in patients undergoing TJR, and SSI and return to OR rates may be lower when compared to universal warfarin therapy.

Levels of Matrix-Degrading Enzymes and Lubricin in Patients With Degenerative Joint Disease Requiring Arthroplasty.

Total joint arthroplasty (TJA) of the hip or knee (THA and TKA) is the primary surgical intervention for individuals with degenerative joint disease (DJD). Although it is commonly thought that shear force on the joint causes the degradation of articular cartilage, it is possible that there are other factors that contribute to the progression of DJD. It is plausible that specific enzymes that degrade the joint are upregulated, or conversely, there is downregulation of enzymes critical for joint lubrication. The aim of this study is to profile collagenase-1, elastase, heparanase, and lubricin levels in patients undergoing TJA in order to determine potential preexisting dysregulation that contributes to the pathogenesis of DJD. Deidentified blood samples were obtained from patients undergoing TJA 1 day pre- and 1 day postoperatively. Plasma samples were analyzed using enzyme-linked immunosorbent assay kits for elastase, collagenase-1, heparanase, and lubricin. In comparison to healthy controls, there were significant increases in circulating collagenase-1, elastase, and lubricin levels in both the preoperative and postoperative samples. There were no significant differences in heparanase levels in the preoperative or postoperative samples. Comparing the preoperative versus postoperative patient samples, only lubricin demonstrated a significant change. The results of this study confirm that patients undergoing TJA have preexisting alterations in the levels of matrix-degrading enzymes and lubricin. The alterations observed in this study may provide insight into the pathogenesis of DJD.

Functional Impairment of Patients Undergoing Surgical Correction for Charcot Foot Arthropathy.

BACKGROUND: Investigations using the Medical Outcomes Study Short Form 36 Healthy Survey (SF-36) and the American Orthopaedic Foot & Ankle Society Diabetic Foot Questionnaire (AOFAS-DFQ) have demonstrated a poor quality of life in patients with Charcot foot arthropathy. The Short Musculoskeletal Function Assessment (SMFA) questionnaire has been widely used in patients with a broad range of musculoskeletal disorders. METHODS: Twenty-five consecutive patients undergoing operative correction for diabetes-related Charcot foot arthropathy of the midfoot completed the SMFA prior to undergoing surgery. There were 16 males and 9 females. The average body mass index (BMI) was 37.4 (range 25.8-50.2), and the average hemoglobin A1c was 7.5 (range 5.3-10.1) prior to surgery. RESULTS: All 25 patients exhibited significant impairment in all 6 domains of the SMFA ( P < .0001) as compared to the normative data. There was a high correlation between each of the 6 domains of the SMFA, even after correcting for BMI. CONCLUSION: Charcot foot severely impaired the quality of life in patients beyond the impact of morbid obesity. This impairment equally impacted all of the functional and emotional domains measured with the SMFA as compared with population norms. This investigation provides a benchmark for measuring the impact of operative correction of the deformity. In addition, the SMFA appears to be a valid tool for measuring impairment in this complex patient population. LEVEL OF EVIDENCE: Level II, prospective comparative investigation.