Determining Appropriateness of Total Joint Arthroplasty for Hip and Knee Osteoarthritis: A Patient-Centred Conceptual Model.

INTRODUCTION: Total joint arthroplasty (TJA) for osteoarthritis is one of several treatment options with benefits and harms that patients value differently. However, the process for determining TJA appropriateness does not sufficiently acknowledge patient perspectives. The aim of this paper is to propose an evidence-informed patient-centred conceptual model for elective TJA appropriateness for hip and knee osteoarthritis. METHODS: Our interprofessional team developed a conceptual model for determining the appropriateness of adults considering elective TJA. The model was informed by a review of the evidence, a qualitative study we conducted with adults who underwent TJA for osteoarthritis to determine barriers and facilitators to the use of appropriateness criteria, and the research and clinical experience of team members. RESULTS: Appropriateness is providing health services (e.g., TJA) with net benefits to the right patient at the right time. The proposed Patient-centred Elective TJA Appropriateness Conceptual Model involves three key steps. First, assess adults with osteoarthritis to determine eligibility for TJA. Second, acknowledge the patient's informed preferences including their expectations and goals. Third, explore and support their mental and physical readiness for TJA. Given that osteoarthritis is a chronic condition, these steps can be revisited over time with patients. DISCUSSION AND CONCLUSION: Our proposed conceptual model reconceptualises the appropriateness of TJA to be more patient-centred. Hence, this approach has the potential to be a more inclusive approach and ensure patients undergoing TJA are eligible, ready to proceed, and achieve what matters most to them. Future research is needed to test and validate the model.

Muscle Activity and Biomechanics While Descending a Staircase After Total Knee Arthroplasty: A Study Comparing Different Posterior Stabilized and Medial Ball-and-Socket Designs.

BACKGROUND: Many patients report more difficulty when descending stairs compared to level walking after total knee arthroplasty (TKA). Different implant designs can affect knee biomechanics and muscle activity during gait, but their effect during stair descent is unclear. The purpose of this study was to evaluate knee biomechanics and muscle activations of quadriceps, hamstrings, and gastrocnemius muscles during a stair descent task in patients who underwent TKA with either a posterior stabilized (PS) or medial ball-and-socket (MBS) implant and to compare them to a group of healthy controls. METHODS: There were 28 TKA patients who were randomized to either an MBS (n = 14) or PS (n = 14) implant and were compared with 14 controls. Patients visited the biomechanics lab approximately 12 months after TKA, where knee biomechanics and muscle activity were measured as they descended a 3-step staircase. RESULTS: Compared to the MBS and control groups, the PS group descended the stairs with a reduced knee flexion angle and greater hamstring muscle activation throughout single limb support. Knee joint moments and power were similar between the MBS and PS groups, but neither reached the level of the control group. CONCLUSIONS: Lower knee flexion angles and increased hamstring muscle activity indicated that the PS group descended the stairs with a stiffer knee gait pattern than the MBS group. The MBS implant design may provide additional stability as patients require less muscle activity than the PS group.

Knee biomechanics variability before and after total knee arthroplasty: an equality of variance prospective study.

This study evaluated gait variability in patients before and after total knee arthroplasty (TKA) using the equality of variance method to determine where variability differences occur in the movement cycle. Twenty-eight patients underwent TKA with cruciate-sacrificed implants. Patients underwent motion analysis which measured knee biomechanics as they walked overground at their preferred pace before and 12 months after TKA. Equality of variance results were compared with 14 healthy controls of similar age. Before surgery, patients had reduced knee extension moment variability throughout the early stance phase (4-21% gait cycle, p < 0.05) compared to controls. Knee power variability was lower preoperatively compared to controls for most of the stance phase (0-13% and 17-60% gait cycle, p < 0.05). Sagittal knee moment and power variability further decreased following TKA. Knee extension moment variability was lower postoperatively throughout stance phase compared to preoperatively (4-22% and 36-60% gait cycle, p < 0.05) and compared to controls (4-30% and 45-60% gait cycle, p < 0.05). Knee power variability remained lower following TKA throughout stance phase compared to preoperatively (10-24% and 36-58% gait cycle, p < 0.05) and controls (3-60% gait cycle, p < 0.05). TKA patients may be less stable, and this may be in part due to an unresolved adaptation developed while awaiting TKA surgery and the cruciate sacrificing design of the implants utilized in this study.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

Midterm Outcomes in Lateral Unicompartment Knee Replacement: The Effect of Patient Age and Bearing Choice.

Isolated lateral compartment knee osteoarthritis (OA) affects between 7 and 10% of patients with knee OA. Although lateral unicompartmental knee arthroplasty (UKA) is an accepted treatment to manage this condition, it is performed relatively infrequently. The aim of this study was to evaluate the mid-term survivorship, radiographic outcomes, and patient-reported outcome measures (PROMs). We performed a retrospective review of a prospectively maintained database of consecutive isolated lateral UKAs performed by a single surgeon at an academic institution between September 2007 and December 2015. Our primary outcome was failure defined as revision surgery to total knee arthroplasty (TKA). Secondary outcomes included any additional surgery for any other reason. Forty-nine consecutive patients (27 females) with median age of 54.7 years (45.2-82.2) met the inclusion criteria. The survival rate for the whole cohort was 86.1% (95% confidence interval [CI]: 73.2-99.0) at 10 years as defined by conversion to TKA. There were a total of four lateral UKAs (all mobile bearings) revised to TKAs. The entire cohort demonstrated statistically significant improvements from preoperative PROMs compared with the most recent postoperative PROMs including the Western Ontario and McMaster Universities Osteoarthritis Index, Knee injury and Osteoarthritis Outcome Score, and Tegner activity scale at a median 8.8 (1.7-12.2) years follow-up. Patients with mobile bearing underwent higher revision to TKA and reoperation for all indications compared with fixed-bearing lateral UKA. In this relatively young cohort, lateral UKA yielded acceptable long-term survival and satisfactory improvement in functional outcomes. Patients who had fixed-bearing implants had similar improvement and trended toward lower revision rates than those with mobile-bearing implants. Level III therapeutic: retrospective Study was performed.

Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review.

➢: Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks. ➢: IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty. ➢: Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required. ➢: A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.

Evaluation of Safety and Medium-Term Functional Outcomes of a Medial Fixed-Bearing Unicompartmental Knee Arthroplasty with Ultra-Highly Cross-Linked Polyethylene.

The primary objective of this study was to evaluate the in vivo safety of a unicompartmental knee arthroplasty design with sequentially annealed cross-linked polyethylene by evaluating reoperation rate, in particular those related to excessive polyethylene wear or breakage. The secondary objective was to examine functional outcomes via standardized questionnaires. This was a 5-year institutional review board-approved prospective single-surgeon case series of the first 152 consecutive patients with symptomatic medial unicompartmental osteoarthritis implanted with a partial knee replacement between May 2010 and December 2014. Study participants were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthrtis Index (WOMAC) questionnaires at preoperation and 2 to 5 years postoperation. Major complications and all reoperations were recorded and we produced Kaplan-Meier survivorship curves with the end point of revision to TKA. Pre- and postoperative differences for KOOS and WOMAC were evaluated by paired t-tests. The median length of follow-up was 7.2 (0-9.72) years. Seven patients required revision surgery to TKA (4.9% of patients): four with progression of arthritis in other compartments, two for infection, and one for loosening of the femoral component and subsequent progression of pain. There were no failures of polyethylene. Survival of cohort was 99.3 and 97.9% at 2 and 5 years, respectively. Patients significantly improved (p-value < 0.001) between preoperative assessment and at 2 years, with no decline at 5 years postoperation. These preliminary midterm results with this fixed-bearing design and cross-linked polyethylene were encouraging with no catastrophic failures of polyethylene. Patient reported outcomes were significantly improved and revision rates were acceptable and lower than registry reported results.

Mid-Term Evaluation of the Unicompartmental Knee Arthroplasty in Patients with BMI of 40 or Greater.

Limited evidence is available on mid-term follow-up for patients with body mass index (BMI) ≥ 40 receiving a unicompartmental knee arthroplasty (UKA). The primary objective of this study was to investigate survival of the UKA in patients with BMI ≥ 40. Secondary objectives were to assess functional and patient reported outcome measures (PROMs). Survival analysis with endpoint revision of any component for any reason was conducted using Kaplan-Meier technique on 121 knees (103 patients) that underwent UKA with Oxford Phase 3 implant (Oxford Knee, Biomet, Swindon, United Kingdom) between September 2001 and March 2014 by seven surgeons. Survivorship differences were compared using Log Rank (Mantel-Cox) tests, and Cox Proportional Hazard Model was used to assess predictors of failure. Preoperative PROMs were compared at 2 and 5 years postoperatively using paired t-tests. Mean age of patients was 58 years (43-75), mean BMI 43 kg/m2 (40-51), and mean follow-up 7 years (2 months to 15 years). Survival rate for the whole cohort was 92% at 2 years and 86% at 5 years. Females had a significantly higher revision rate than males (p = 0.043). A total of 19 knees required revision (16 to TKA, 2 polyethylene liner exchanges, and 1 femoral component and liner revision). With respect to PROMs, there was a significant improvement at 2 and 5 years (p < 0.001) on 4 of 5 knee injury and osteoarthritis outcome score subscales. The mid-term survival rate for the Oxford UKA in patients with morbid obesity is similar to that of other nondesigner patient series with BMI ≥ 30, which provides further evidence for the safety of the implant in this patient population with significant improvements on PROMs at short and mid-term follow-up.

The Clinical Outcome of Patellofemoral Arthroplasty vs Total Knee Arthroplasty in Patients Younger Than 55 Years.

BACKGROUND: Patellofemoral osteoarthritis affects 10% of patients older than 40 years and is commonly treated by patellofemoral joint arthroplasty (PFA) or a total knee arthroplasty (TKA). PFA is a more conservative approach with documented faster recovery. No study to date has compared both approaches with respect to patient-reported outcome measures in patients younger than 60 years. METHODS: A retrospective case-matched cohort based on age, sex, body mass index, and side of 23 PFAs (in 19 patients) operated on by 2 surgeons and of 23 TKAs (23 patients) operated on by 6 surgeons was included in the study. All patients were younger than 55 years and operated on between March 2010 and September 2015. The Western Ontario and McMaster Osteoarthritic Index, Knee injury and Osteoarthritis Outcome scores, Tegner, and University of California, Los Angeles activity scores were compared between preoperative and minimum 2-year postoperative timepoints between groups. RESULTS: TKA and PFA were comparable on all patient-reported outcome measures at minimum 2-year follow-up; however, PFA patients exhibited statistically significantly larger improvement between 1 year postoperative and 2 years postoperative timepoints (P < .05). All patients improved between preoperative and postoperative timepoints (P < .05). CONCLUSION: Although TKA performed better with respect to functional outcomes at the 1-year mark, at 2-year follow-up, PFA and TKA performed equally well. Our results allow us to conclude that in younger patients with isolated patellofemoral osteoarthritis who desire a more conservative, kinematic-preserving approach, PFA continues to be a practical treatment option yielding early outcomes that compare favorably with TKA.

Patellar maltracking: an update on the diagnosis and treatment strategies.

Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. This is often secondary to an underlying structural abnormality. The clinical evaluation can provide useful clues for the presence of such entity; however, the diagnosis can often be challenging especially in the absence of a documented history of patellar dislocation. Imaging, particularly MRI, can detect subtle features that could lead to the diagnosis, probably even more importantly when there is no clear history of patellar dislocation or before its development. This can provide a road map for formulating a treatment strategy that would be primarily aimed at stabilizing the patellofemoral joint to halt or slow the progression of articular cartilage loss. The purpose of this article is to discuss the clinical and radiologic evaluation of patellar maltracking providing an update on the cross-sectional imaging assessment and also a synopsis of the management options.

Defining growth potential and barriers to same day discharge total knee arthroplasty.

BACKGROUND: Outpatient arthroplasty programs are becoming well established. Adverse event rates have been demonstrated to be no worse than inpatient arthroplasty in the literature for selected patients. The purpose of this study was to determine our rate of outpatient total knee arthroplasty (TKA), examine justification for exclusions, and estimate the proportion of TKAs that can occur safely on an outpatient basis. METHODS: Retrospective case series of 400 consecutive TKAs from Oct 2014 to Mar 2017. Patient demographics, allocation to outpatient surgery vs standard admission, and reason for exclusion from outpatient surgery were recorded. Ninety-day Emergency department (ED) visits, readmission rates, and length of stay (LOS) were compared between groups using independent sample t test and Chi-squared test. RESULTS: Outpatients were younger (p = 0.001), had lower BMI (p < 0.001), and ASA scores (p < 0.001) than inpatients. One hundred twenty-five (31%) TKAs were assigned to outpatient surgery and 123 achieved discharge on the same day. There was no difference in 90-day ED visits (p = 0.889) or readmission rates (p = 0.338) between groups. Reasons for exclusion from outpatient surgery included medical (absolute 43% and relative 31%), distance > one hour from hospital (18%), no help (7%), and other/unclear (10%). LOS was significantly longer for medical than non-medical exclusions (p < 0.001) and for the absolute compared to relative medical exclusions (p = 0.004). CONCLUSION: Outpatient TKA is safe in selected patients, and inclusion can likely be broadened by addressing modifiable exclusions and narrowing medical exclusions. We found that 55% of our TKA population could be appropriate for outpatient surgery.

Quality of Recovery, Postdischarge Hospital Utilization, and 2-Year Functional Outcomes After an Outpatient Total Knee Arthroplasty Program.

BACKGROUND: Outpatient total knee arthroplasty (TKA) has been made possible with advances in perioperative care and standardized clinical inpatient pathways. While many studies report on benefits of outpatient programs, none explore patient-reported outcome measures. As such, our goals were to compare the short-term quality of recovery; highlight postdischarge hospital resources utilization; and report on 2-year functional outcomes scores. METHODS: This was a prospective comparative cohort study of 43 inpatients (43 TKAs) and 43 outpatients (43 TKAs) operated on by a single surgeon between September 28, 2010 and May 5, 2015. All patients were given a diary to complete at 1, 3, 7, 14, and 28 days postoperatively; we collected 90-day complications, readmissions, and emergency department visits; Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores were completed preoperatively and 2 years postoperatively. SPSS (IBM, version 22.0) was used for all statistical analyses. RESULTS: Quality of recovery (QoR-9) was similar in the outpatient TKA group compared with the inpatient group. No statistically significant differences were observed for Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index subscores (P > .05). There was 1 readmission in both outpatient and inpatient groups. Six inpatients and 8 outpatients returned to the emergency department for any reason within 90 days, with no statistical significance observed between the 2 groups (P = .771). CONCLUSION: Outpatient TKA in selected patients produced similar short-term and 2-year patient-reported outcome measures and a comparable 90-day postdischarge hospital resource utilization when compared to an inpatient cohort, supporting further investigation into outpatient TKA.

Predicting hospital length of stay and short-term function after hip or knee arthroplasty: are both performance and comorbidity measures useful?

PURPOSE: Variations in hospital length of stay (LOS) and function are present after hip or knee arthroplasty. Comorbidity and performance measures have been associated with post-operative outcomes. It is however not known if both independently contribute to outcome prediction. The objective of this study was to evaluate the combined predictive ability of comorbidity scores (American Society of Anesthesiologists classification system (ASA), Charlson comorbidity index (CCI), 2008 version of the CCI (CCI08)) and a performance measure (Timed-Up-and-Go (TUG)) on LOS and short-term function in patients undergoing knee or hip arthroplasty. METHODS: One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively with the ASA, CCI, CCI08, and TUG. LOS was determined through administrative data. The Older Americans Resources and Services ADL questionnaire (OARS) was used to assess function two and six weeks after surgery. Logistic regression was used to assess the relationship between pre-operative assessments and LOS and OARS scores. RESULTS: Both the ASA and TUG significantly contributed to LOS prediction. Odds ratio (OR) was 3.57 (95% confidence interval (CI) 1.26-10.07) for the ASA, and 2.18 (95% CI 1.67-4.15) for a one-standard deviation (SD) increase of 4.45 s of the TUG. Only the TUG was predictive of two weeks function and trending towards significance for six weeks function. One SD TUG increase yielded an OR of 2.14 (95% CI 1.53-3.79) for two week function. CONCLUSIONS: The TUG and ASA can be used pre-operatively in combination to predict LOS, and TUG can also be used to predict short-term post-operative function.

Effect of patient decision aid was influenced by presurgical evaluation among patients with osteoarthritis of the knee.

BACKGROUND: Decision aids help patients make total joint arthroplasty decisions, but presurgical evaluation might influence the effects of a decision aid. We compared the effects of a decision aid among patients considering total knee arthroplasty at 2 surgical screening clinics with different evaluation processes. METHODS: We performed a subgroup analysis of a randomized controlled trial. Patients were recruited from 2 surgical screening clinics: an academic clinic providing 20-minute physician consultations and a community clinic providing 45-minute physiotherapist/nurse consultations with education. We compared the effects of decision quality, decisional conflict and surgery rate using Cochran-Mantel-Haenszel χ2 tests and the Breslow-Day test. RESULTS: We evaluated 242 patients: 123 from the academic clinic (61 who used the decision aid and 62 controls) and 119 from the community clinic (59 who used the decision aid and 60 controls). Results suggested a between-site difference in the effect of the decision aid on the patients' decision quality (p = 0.09): at the academic site, patients who used the decision were more likely to make better-quality decisions than controls (54% v. 35%, p = 0.044), but not at the community site (47% v. 51%, p = 0.71). Fewer patients who used decision aids at the academic site than at the community site experienced decisional conflict (p = 0.007) (33% v. 52%, p = 0.05 at the academic site and 40% v. 24%, p = 0.08 at the community site). The effect of the decision aid on surgery rates did not differ between sites (p = 0.65). CONCLUSION: The decision aid had a greater effect at the academic site than at the community site, which provided longer consultations with more verbal education. Hence, decision aids might be of greater value when more extensive total knee arthroplasty presurgical assessment and counselling are either impractical or unavailable.

CONTEXTE: Les aides à la décision guident les patients dans leurs choix quant à l'arthroplastie par prothèse totale, mais l'évaluation préopératoire pourrait modifier leur influence. Nous avons comparé cette influence chez les patients qui envisagent une arthroplastie totale du genou dans 2 cliniques de dépistage chirurgical ayant des processus d'évaluation différents. MÉTHODES: Nous avons effectué une analyse par sous-groupes d'un essai clinique randomisé. Les patients ont été recrutés dans 2 cliniques de dépistage chirurgical : une clinique universitaire offrant des consultations de 20 minutes avec un médecin et une clinique communautaire offrant des consultations de 45 minutes avec un physiothérapeute ou une infirmière et de l'enseignement. Nous avons comparé l'influence sur la qualité des décisions, les conflits décisionnels et le taux d'intervention chirurgicale à l'aide des tests de Cochran-Mantel-Haenszel (χ2) et du test de Breslow-Day. RÉSULTATS: Nous avons évalué 242 patients : 123 de la clinique universitaire (61 qui ont utilisé l'outil et 62 témoins) et 119 de la clinique communautaire (59 qui ont utilisé l'outil et 60 témoins). Les résultats semblaient indiquer une différence entre les sites quant à l'influence de l'aide sur la qualité des décisions des patients (p = 0,09) : au site universitaire, les patients qui l'ont utilisée étaient plus susceptibles de prendre des décisions de qualité que les témoins (54 % c. 35 %, p = 0,044), mais ce n'était pas le cas au site communautaire (47 % c. 51 %, p = 0,71). Moins de patients qui ont utilisé les aides à la décision au site universitaire qu'au site communautaire avaient vécu un conflit décisionnel (p = 0,007) (33 % c. 52 %, p = 0,05 au site universitaire; 40 % c. 24 %, p = 0,08 au site communautaire). L'influence de l'outil sur les taux d'intervention chirurgicale était la même aux 2 sites (p = 0,65). CONCLUSION: L'aide à la décision a eu un plus grand effet au site universitaire qu'au site communautaire, qui offrait de plus longues consultations et plus d'enseignement verbal. Ce type d'outil aurait donc plus de valeur dans les cas où il est difficile ou impossible d'offrir une évaluation préopératoire détaillée et des conseils approfondis pour l'arthroplastie totale du genou.

Evaluation of a Patient Decision Aid for Unicompartmental or Total Knee Arthroplasty for Medial Knee Osteoarthritis.

BACKGROUND: Many patients with isolated medial compartment osteoarthritis are candidates for either unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). A novel patient decision aid (PDA) was developed to educate patients on both interventions and prepare them for making the decision with their surgeon. The study objective was to evaluate the acceptability and usefulness of a PDA for informing and helping patients reach a surgical preference without increasing decisional conflict. METHODS: A PDA was developed in accordance with the criteria listed by Ottawa Decision Support Framework and prospectively tested in UKA and TKA patients, who were mailed the PDAs to complete at home along with outcome measures before surgeon consultation. Of 50 patients who consented to participate, 45 patients (26 men, 19 women) used the PDA. Quantitative analysis of acceptability, decisional conflict, knowledge, and preferred surgical option was then performed. RESULTS: Mean patient age was 64.6 years (range, 50-80 years). Patients rated the PDA as acceptable: 84.4% indicated balanced presentation of information and 77.8% asserted that PDA helped them to make decisions between UKA and TKA. Mean knowledge score was 86.6% and total decisional conflict was 19.7 out of 100. Of 45, 33 stated a preferred option (24 UKA; 9 TKA; 12 unsure). CONCLUSION: Patients understood the majority of the benefits and risks for each surgical option without increasing decisional conflict. The decision aid for advanced medial compartment osteoarthritis is shown to be acceptable and useful for choosing between UKA and TKA.

Cost savings of outpatient versus standard inpatient total knee arthroplasty.

BACKGROUND: With diminishing reimbursement rates and strained public payer budgets, a high-volume inpatient procedure, such as total knee arthroplasty (TKA), is a common target for improving cost efficiencies. METHODS: This prospective case-control study compared the cost-minimization of same day discharge (SDD) versus inpatient TKA. We examined if and where cost savings can be realized and the magnitude of savings that can be achieved without compromising quality of care. Outcome variables, including detailed case costs, return to hospital rates and complications, were documented and compared between the first 20 SDD cases and 20 matched inpatient controls. RESULTS: In every case-control match, the SDD TKA was less costly than the inpatient procedure and yielded a median cost savings of approximately 30%. The savings came primarily from costs associated with the inpatient encounter, such as surgical ward, pharmacy and patient meal costs. At 1 year, there were no major complications and no return to hospital or readmission encounters for either group. CONCLUSION: Our results are consistent with previously published data on the cost savings associated with short stay or outpatient TKA. We have gone further by documenting where those savings were in a matched cohort design. Furthermore, we determined where cost savings could be realized during the patient encounter and to what degree. In carefully selected patients, outpatient TKA is a feasible alternative to traditional inpatient TKA and is significantly less costly. Furthermore, it was deemed to be safe in the perioperative period.

CONTEXTE: Dans le contexte de budgets publics serrés et de taux de remboursement à la baisse, une intervention chirurgicale en service interne à volume élevé, comme l'arthroplastie totale du genou, est souvent ciblée pour améliorer le rapport coût­efficacité. MÉTHODES: Cette étude cas­témoins prospective a fait une analyse de minimisation des coûts de l'arthroplastie totale du genou en chirurgie d'un jour et en service interne. Nous avons examiné si et où des économies peuvent être réalisées et l'ampleur des économies pouvant être obtenues sans compromettre la qualité des soins. Les variables dépendantes, notamment les coûts détaillés des cas, le taux de retour à l'hôpital et les complications, ont été documentées, puis comparées entre les 20 premiers cas de chirurgie d'un jour et 20 cas­témoins appariés de chirurgie en service interne. RÉSULTATS: Pour chaque appariement cas­témoins, l'arthroplastie totale du genou en chirurgie d'un jour était moins coûteuse que la chirurgie en service interne et a généré des économies médianes d'environ 30 %. Les économies découlaient principalement des coûts associés à l'hospitalisation du patient tels que les coûts de l'unité de soins chirurgicaux, de la pharmacie et des repas du patient. Après 1 an, ni l'un ni l'autre des 2 groupes ne présentait de complications majeures, de retours à l'hôpital ou de réadmissions. CONCLUSION: Nos résultats concordent avec les données antérieures publiées sur les économies associées à l'arthroplastie totale du genou pratiquée en chirurgie d'un jour ou en service interne de courte durée. Nous sommes allés plus loin en documentant également où les économies se situaient dans un modèle cas­témoins. De plus, nous avons déterminé les aspects de la rencontre avec le patient où des économies pourraient être réalisées et l'ampleur de ces économies. Chez des patients soigneusement choisis, l'arthroplastie totale du genou en chirurgie d'un jour est une solution de rechange envisageable à l'arthroplastie totale du genou traditionnelle en service interne et est beaucoup moins coûteuse. De plus, elle a été jugée sécuritaire en période périopératoire.

Can Surgeons Adequately Capture Adverse Events Using the Spinal Adverse Events Severity System (SAVES) and OrthoSAVES?

BACKGROUND: Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from-an aid that may improve adverse-event reporting by physicians. QUESTIONS/PURPOSES: The primary objective was to compare surgeons' adverse-event reporting with reporting by independent clinical reviewers using SAVES Version 2 (SAVES V2) and OrthoSAVES in elective orthopaedic procedures. METHOD: This was a 10-week prospective study where SAVES V2 and OrthoSAVES were used by six orthopaedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures to the point of patient discharge. Neither surgeons nor reviewers received specific training on adverse-event reporting. Surgeons were aware of the ongoing study, and reported adverse events based on their clinical interactions with the patients. Reviewers recorded adverse events by reviewing clinical notes by surgeons and other healthcare professionals (such as nurses and physiotherapists). Adverse events were graded using the severity-grading system included in SAVES V2 and OrthoSAVES. At discharge, adverse events recorded by surgeons and reviewers were recorded in our database. RESULTS: Adverse-event data for 164 patients were collected (48 patients who had spine surgery, 51 who had hip surgery, 34 who had knee surgery, and 31 who had shoulder surgery). Overall, 99 adverse events were captured by the reviewers, compared with 14 captured by the surgeons (p < 0.001). Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers. A total of 93 of 99 (94%) adverse events reported by reviewers required only simple or minor treatment and had no long-term adverse effect. Three patients experienced adverse events that resulted in use of invasive or complex treatment that had a temporary adverse effect on outcome. CONCLUSION: Using SAVES V2 and OrthoSAVES, independent reviewers reported more minor adverse events compared with surgeons. The value of third-party reviewers requires further investigation in a detailed cost-benefit analysis. LEVEL OF EVIDENCE: Level II, therapeutic study.

Assessing functional recovery shortly after knee or hip arthroplasty: a comparison of the clinimetric properties of four tools.

BACKGROUND: Following hip or knee arthroplasty, it is clinically warranted to get patients functional as quickly as possible. However, valid tools to assess function shortly after knee or hip arthroplasty are lacking. The objective was to compare the clinimetric properties of four instruments to assess function shortly after arthroplasty. METHODS: One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively, 1 and 2 days postoperatively, and 2 and 6 weeks postoperatively with the Timed Up and Go (TUG), Iowa Level of Assistance Scale (ILAS), Postoperative Quality of Recovery Scale (PQRS), and Readiness for Hospital Discharge Scale (RHDS). Descriptive data, floor and ceiling effects, responsiveness, interpretation and construct validity were determined. RESULTS: Only the ILAS and RHDS support subscale demonstrated floor or ceiling effects. A large deterioration from preoperative to postoperative, followed by large improvements after surgery were seen in the TUG and ILAS scores. The RHDS personal status subscale and the PQRS pain and function dimensions demonstrated large improvements after surgery. Changes in the RHDS global scale and personal status subscale, PQRS pain dimension and TUG were significantly related to patient perceived improvement. Minimal important changes were obtained for the RHDS global (1.1/10) and personal status subscale (2.3/10), and the TUG (43.4 s at 6 weeks). For construct validity, the PQRS function dimension and RHDS were moderately related to the TUG or ILAS. The correlation between TUG and ILAS was high from preoperative to postoperative day 2, but substantially decreased at 2 and 6 weeks. CONCLUSIONS: The TUG and RHDS personal status subscale demonstrated the best clinimetric properties to assess function in the first 6 weeks after hip or knee arthroplasty.