Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center.

Background: Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose: We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods: We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results: Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion: In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

Social Risk Determinants for Successful Same Calendar Day Discharge in Total Joint Arthroplasty.

Background: While many studies have examined the impact of comorbidities on the success of same calendar day discharge (SCDD) in total joint arthroplasty (TJA), literature surrounding the impact of social determinants is lacking. Purpose: We sought to investigate the relationship between various social determinants and success of SCDD after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: We conducted a retrospective review of 1160 THA and 1813 TKA performed at a single academic institution between November 2020 and August 2022. Social factors including substance use, occupation, marital status, income, and participation in physical exercise were included. In addition, aspects of discharge planning were reviewed such as living situation and transportation details. Results: Overall, 952 (32%) patients had successful SCDD, whereas 2021 (68%) patients were discharged on postoperative day 1 (POD1) or greater. Successful SCDD patients were more likely to have health care (4.8% vs 2.5%) and active (5.4% vs 4.6%) rather than sedentary occupations, be married (79.6% vs 67.4%), have access to transportation (95.6% vs 92.9%), live in a higher median income area ($64,044 [16,183] vs $61,572 [14,594]), and exercise weekly (62.6% vs 23.9%). Interestingly, the successful patients had more stories in their homes (1.62 [0.56] vs 1.43 [0.53]), more stairs to enter their homes (5.19 [5.22] vs 4.60 [5.24]), lived farther from the hospital (43.3 [138.0] vs 32.0 [75.9] miles), and a higher prevalence of alcohol use (60.7% vs 44.7%) and tobacco use (19.3% vs 17.3%). Conclusion: These findings may help arthroplasty surgeons to better understand the social factors that contribute to successful SCDD in TJA patients, ultimately aiding in patient selection and preoperative counseling.

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

A Novel Achilles Tendon Repair Technique Utilizing a Bio-Composite Scaffold for a Sub-Acute Tear.

Achilles tendon ruptures are prevalent musculoskeletal injuries accounting for 20% of all large tendon ruptures with a re-rupture rate of 2.1-8.8%. Ineffectual management of these injuries can lead to a significant loss in push-off strength and overall ankle function. The field of orthopedic surgery has shown an increasing interest in biologic augmentation. Encouraged by its success in various other applications, this approach holds promise for potentially enhancing outcomes in Achilles tendon repairs, especially in poor tendon tissue. The BioBrace® (ConMed, New Haven, Connecticut) is a biocomposite scaffold made of highly porous type I collagen and bioresorbable poly (L-Lactide) (PLLA) microfilaments. It can be applied in conjunction with Achilles tendon repair or reconstruction. It provides immediate strength to the augmented repair upon implantation and simultaneously promotes new, organized tissue growth throughout its resorptive phase. Here, we outline a technique to effectively augment an acute Achilles tendon repair utilizing the BioBrace® reinforced bio-inductive implant.

Fracture of a Metal-Backed Ceramic Liner After Total Hip Arthroplasty: A Case Report.

Total hip arthroplasty (THA) is a common procedure that has become increasingly prevalent in a younger patient population. With improvements in prostheses and materials, the survivorship of implants has increased. Historically, the excellent wear characteristics of ceramic-on-ceramic (CoC) implants made them an appealing choice compared to other bearing options. Yet, the potential benefits of the bearing longevity related to the wear characteristics have been combated by their unique causes of failure such as implant fracture and squeaking. Metal-backed ceramic liners were developed to minimize impingement-related chipping at the periphery of the implant that may propagate to catastrophic implant fracture. We report a case involving a fracture of a metal-backed ceramic liner that presented with months of pain and crepitus with no overt signs of fracture on imaging.

The Complication of a Retained Broken Distal Interlocking Screw Within a Cephalomedullary Nail During Conversion Hip Arthroplasty: A Case Report.

In patients who undergo femoral fracture fixation with a cephalomedullary nail, the breakage of one or more of the distal interlocking screws is a well-described phenomenon. The presence of a broken interlocking screw in patients who require the removal of their cephalomedullary nail presents a unique challenge. The broken interlocking screw may be retrieved, or the screw may be retained if it is not engaged within the nail and the nail can safely be removed while leaving the broken screw fragment behind. We report a hip conversion arthroplasty case with a broken interlocking screw where the nail was removed with ease and the broken screw was assumed to have been left behind. Cerclage wires were placed for an apparent proximal femoral fracture. Postoperative X-rays demonstrated a large lucency tracking from the prior location of the distal interlocking screw to the calcar region. This finding made it evident that the broken screw had been retained in the nail and was dragged up the femur upon nail removal, causing a large gouge spanning the entire femur.

When Does the Knee Feel Normal Again: A Cross-Sectional Study Assessing the Forgotten Joint Score in Patients After Total Knee Arthroplasty.

BACKGROUND: The forgotten joint score (FJS) is a recent scoring system that assesses how natural the prosthesis feels after total joint arthroplasty. Although the FJS has been extensively applied in populations with total hip prosthetics, less is known about the patients undergoing total knee arthroplasty (TKA). The purpose of this study is to investigate the temporal relationship between TKA and the FJS. METHODS: We evaluated 566 patients after TKA using the FJS questionnaire. Scores were calculated at the follow-up intervals of 1 (n = 79), 6 (n = 78), 12 (n = 81), 24 (n = 100), 36 (n = 76), 48 (n = 75), and 60 (n = 77) months. The scores ranged from 0-100, with a higher score indicating a more natural or "forgotten" joint. RESULTS: Postoperative FJS averages were 39.3 ± 27.4 at 1 month, 59.4 ± 28.3 at 6 months, 72.5 ± 24.2 at 1 year, 76.4 ± 23.4 at 2 years, 75.1 ± 24.2 at 3 years, 68.6 ± 28.7 at 4 years, and 64.4 ± 29.0 at 5 years. The average score at 1 month was significantly lower than the average scores at all other intervals. The average score at 6 months was significantly lower than the average scores at 12, 24, and 36 months. The average score at 60 months was significantly lower than the average score at 24 months. CONCLUSION: Based on the findings of this study, patients can expect marked improvement in the natural feel of the prosthesis during the first year after TKA, slight continued improvement at 2 and 3 years, and a decline after 4 years.

A Proactive Approach to High Risk Delirium Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Delirium is a common complication among elderly patients undergoing total joint arthroplasty (TJA). Its incidence has been reported from 4% to 53%. The Centers for Medicare and Medicaid Services consider delirium following TJA a "never-event." The purpose of this study is to evaluate a simple perioperative protocol used to identify delirium risk patients and prevent its incidence following TJA. METHODS: Our group developed a protocol to identify and prevent delirium in patients undergoing TJA. All patients were screened and scored in the preoperative assessment, on criteria such as age, history of forgetfulness, history of agitation or visual hallucinations, history of falls, history of postoperative confusion, and inability to perform higher brain functions. Patients were scored on performance in a simple mental examination. The patients were classified as low, medium, or high risk. Patients who were identified as high risk were enrolled in a delirium avoidance protocol that minimized narcotics and emphasized nursing involvement and fluids administration. RESULTS: Five of 7659 (0.065%) consecutive TJA patients from 2010 to 2015 developed delirium. A total of 422 patients were identified as high risk. All 5 patients who suffered delirium were within the high risk group. No low or medium risk patients suffered a delirium complication. Three (0.039%) patients suffered drug-induced delirium, 1 (0.013%) had delirium related to alcohol withdrawal, and 1 (0.013%) had delirium after a systemic infection. CONCLUSION: This protocol is effective in identifying patients at high delirium risk and diminishing the incidence of this complication by utilizing a simple screening tool and perioperative protocol.

The Direct Anterior Approach Does Not Increase Return to Function Following Hemiarthroplasty for Femoral Neck Fracture.

The purpose of this study was to evaluate functional outcomes for hemiarthroplasty using a direct anterior approach or a direct lateral approach for femoral neck fracture. This retrospective review used data collected from a single institution between 2006 and 2016. Eighty-five and 75 consecutive patients who underwent hemiarthroplasty via a direct anterior approach and a direct lateral approach, respectively, met inclusion criteria. All patients with femoral neck fractures were treated by 1 of 2 fellowship-trained orthopedic surgeons using the direct anterior approach or the direct lateral approach to hemiarthroplasty. Disposition, ambulation, and other perioperative surgical outcomes were compared between the cohorts. Compared with the direct lateral cohort, the direct anterior cohort had a shorter mean operative time (2.4 minutes, P<.01), a shorter mean length of hospital stay (2.7 days, P<.01), and a smaller mean decrease in hemoglobin postoperatively (0.7 g/dL, P<.01). No significant difference was observed between the cohorts for postoperative disposition, the number of feet ambulated on the second postoperative day, or the prevalence of ambulatory decline at 4- to 6-week and 4- to 6-month follow-up visits. Compared with the direct lateral approach, the direct anterior approach may benefit patients by small, but statistically significant, improvements in blood loss, surgical time, and length of hospital stay after hemiarthroplasty. However, the direct anterior approach does not appear to decrease the likelihood of transfer to a skilled nursing facility postoperatively or accelerate return to preoperative function. [Orthopedics. 2017; 40(6):e1055-e1061.].

Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?

BACKGROUND: Periprosthetic joint infection (PJI) is an important cause of failure in total knee arthroplasty. Irrigation and debridement including liner exchange (I&D/L) success rates have varied for acute PJI. The purpose of this study is to present results of a specific protocol for I&D/L with retention of total knee arthroplasty components. METHODS: Sixty-seven consecutive I&D/L patients were retrospectively evaluated. Inclusion criteria for I&D/L were as follows: fewer than 3 weeks of symptoms, no immunologic compromise, intact soft tissue sleeve, and well-fixed components. I&D/L consisted of extensive synovectomy; irrigation with 3 L each of betadine, Dakin's, bacitracin, and normal saline solutions; and exchange of the polyethylene component. Postoperatively, all patients were treated with intravenous antibiotics. Infection was considered eradicated if the wound healed without persistent drainage, there was no residual pain or evidence of infection. RESULTS: Forty-six patients (68.66%) had successful infection eradication regardless of bacterial strain. Those with methicillin-resistant Staphylococcus aureus (MRSA) had an 80% failure rate and those with Pseudomonas aeruginosa had a 66.67% failure rate. The success rate for bacteria other than MRSA and Pseudomonas was 85.25%. CONCLUSION: Our protocol for I&D/L was successful in the majority of patients who met strict criteria. We recommend that PJI patients with MRSA or P aeruginosa not undergo I&D/L and be treated with 2-stage revision. For nearly all other patients, our protocol avoids the cost and patient morbidity of a 2-stage revision.