Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes.

INTRODUCTION: As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay. MATERIALS AND METHODS: We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences. RESULTS: A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts. CONCLUSION: Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery. LEVEL III EVIDENCE: Retrospective Cohort Study.

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients.

PURPOSE: Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses. RESULTS: Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery. CONCLUSION: This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Abstract Submission and Acceptance Rates for Men and Women in Academic Pediatric Orthopaedic Surgery: An Analysis of POSNA Annual Meeting Abstract Submissions 2012-2015.

BACKGROUND: It has recently been demonstrated that women members of the Pediatric Orthopaedic Society of North America (POSNA) participate at the Annual Meeting at disproportionately lower rates than men members, as defined by accepted abstract(s). We hypothesize that this discrepancy is associated with lower abstract submission rates by women members. METHODS: POSNA membership directories for the years 2012-2015 were used to record the name, sex, membership category, and years of membership for each member. Final programs for Annual Meetings and abstract submission records for the same time period were used to record the number of accepted and rejected abstracts for each member. General estimating equations with a binomial model and logit link were used to compare the proportion of abstract acceptances between sexes across years. RESULTS: During the period 2012-2015, active members included 534 men (83.8%) and 103 women (16.2%), whereas candidate members included 207 men (64.7%) and 113 women (35.3%). When active and candidate members were considered collectively, men were significantly more likely to have an accepted abstract (P=0.009) and this significant difference did not change over the 4-year period (P=0.627). However, men submitted significantly more abstracts per member per year than women (means: 1.5 abstracts/man/y; 0.8 abstracts/woman/y; P<0.001). This held true for both candidate members (early career) (P=0.001) as well as active members (mid-career) (P<0.001). When the total number of abstract submissions per year per member was taken into account, the percentage of abstract acceptances was similar for men and women (men=42%, women=40%; P=0.847). CONCLUSIONS: Abstract acceptance rates were similar for women and men members of POSNA for the 2012-2015 Annual Meetings. However, men had a significantly greater number of abstract submissions per member than women, and consequently, men presented a higher proportion of abstracts relative to their membership numbers. This supports our hypothesis that the disproportionately lower rate of active participation amongst women members at POSNA Annual Meetings, defined as abstract acceptance, is due to lower rates of abstract submissions, rather than to lower rates of acceptances. LEVEL OF EVIDENCE: It is not applicable as it is not a clinical or basic science study.

Predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children.

BACKGROUND: Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion. METHODS: We retrospectively reviewed the records of patients younger than 18 years of age with knee effusions who underwent arthrocentesis at our institution from 2005 to 2013. Patients with either septic arthritis (positive joint fluid culture or synovial white blood-cell count of >60,000 white blood cells/mm(3) with negative Lyme titer) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis) were included. To avoid misclassification bias, undiagnosed knee effusions and joints with both a positive culture and positive Lyme titers were excluded. Historical, clinical, and laboratory data were compared between groups to identify variables for comparison. Binary logistic regression analysis was used to identify independent predictive variables. RESULTS: One hundred and eighty-nine patients were studied: 23 with culture-positive septic arthritis, 26 with culture-negative septic arthritis, and 140 with Lyme disease. Multivariate binary logistic regression identified pain with short arc motion, history of fever reported by the patient or a family member, C-reactive protein of >4 mg/L, and age younger than 2 years as independent predictive factors for septic arthritis. A simpler model was developed that showed that the risk of septic arthritis with none of these factors was 2%, with 1 of these factors was 18%, with 2 of these factors was 45%, with 3 of these factors was 84%, or with all 4 of these factors was 100%. CONCLUSIONS: Although septic arthritis of the knee and Lyme monoarthritis share common features that can make them difficult to distinguish clinically, the presence of pain with short arc motion, C-reactive protein of >4.0 mg/L, patient-reported history of fever, and age younger than 2 years were independent predictive factors of septic arthritis in pediatric patients. The more factors that are present, the higher the risk of having septic arthritis. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Septic Arthritis of the Elbow in Children: Clinical Presentation and Microbiological Profile.

BACKGROUND: Septic arthritis of the elbow in children is a rare but important musculoskeletal infection, and there is little published data to guide treating clinicians. The purpose of this study was to describe the clinical presentation and diagnostic findings, associated pathology, and microbiological profile of septic arthritis of the elbow in a pediatric population. METHODS: We retrospectively analyzed a consecutive series of children who had an elbow arthrocentesis for presumed septic arthritis and whose joint aspirates were positive for microbial growth. Data collected included demographics, presenting signs and symptoms, imaging, and laboratory data, including culture results. RESULTS: Twelve children underwent diagnostic arthrocentesis of the elbow joint for septic arthritis at an average age of 6 years and 9 months (range, 2 mo to 13 y and 7 mo). Every child had pain, localized erythema and edema, and restricted range of motion; 10/12 were febrile. Mean duration of symptoms prior to joint tap was 4 days (range, 1 to 14 d). Concurrent osteomyelitis was found in 7 patients, as confirmed with magnetic resonance imaging (MRI): 5 at initial presentation and 2 after readmission for persistent symptoms. Causative pathogens were MSSA (7), MRSA (2), Group G streptococcus (1), Pseuodomonas aureginosa (1), and Streptococcus pneumonia (1). ESR was >40 mm/h in 8/11 patients, CRP was >2 mg/dL in all patients, and synovial WBC count was >50,000 cells/mm in 8/9 patients. One patient developed fulminant sepsis during hospitalization and 2 children were readmitted within 30 days of discharge for unrecognized osteomyelitis and/or recurrence of septic arthritis of the elbow. CONCLUSION: In 12 children studied with septic arthritis, S. aureus was the most common pathogen. Diagnosis is often delayed, and in most cases inflammatory markers were elevated (ESR>40 mm/h, CRP>2 mg/dL). Concomitant osteomyelitis is quite common, and therefore magnetic resonance imaging should be considered as part of the diagnostic work-up for this condition. LEVEL OF EVIDENCE: Level IV­Case series.