Outcomes in Arthroplasty Procedures Performed for Femoral Neck Fractures Does Approach Affect Outcome?

BACKGROUND: The surgical approach used for arthroplasty in the setting of hip fracture has traditionally been decided based on surgeon preference. This study analyzed the ef-fect of the surgical approach on hospital quality measures, complications, and mortality in patients treated with hip arthroplasty for fracture fixation. METHODS: A cohort of consecutive acute hip fracture pa-tients who were 60 years of age or older and who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) at one academic medical center between January 2014 and January 2018 was included. Patient demographics, length of stay (LOS), surgery details, complications, ambulation at dis-charge, discharge location, readmission, and mortality were recorded. Two cohorts were included based on the surgical approach: the anterior-based cohort included the direct an-terior and anterolateral approaches and the posterior-based cohort included direct lateral and posterior approaches. RESULTS: Two hundred five patients were included: 146 underwent HA (81 anterior-based and 65 posterior-based) and 79 underwent THA (37 anterior-based and 42 posterior-based). The mean age of the HA and THA cohorts was 84.1 ± 7.5 and 73.7 ± 8.0 years, respectively. There was no dif-ference in LOS, time to surgery, or surgical time between the two cohorts for HA and THA. There were no differences in perioperative complications, including dislocation, ob-served based on surgical approach. No difference was found between readmission rates and mortality. CONCLUSION: In this cohort of hip fracture arthroplasty patients, there was no difference observed in hospital quality measures, readmission, or mortality in patients based on sur-gical approach. These results are in contrast with literature in elective arthroplasty patients supporting the use of an anterior approach for potential improved short-term outcomes.

Should high-risk patients seek out care from high-volume surgeons?

Aims: Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Methods: Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Results: Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. Conclusion: The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

Are We Moving in the Right Direction? Demographic and Outcome Trends in Same-day Total Hip Arthroplasty From 2015 to 2020.

INTRODUCTION: Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS: We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS: In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION: More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE: III, Retrospective Review.

Approach-Based Complication Rates of Total Hip Arthroplasty in the Medicare Population.

INTRODUCTION: The direct anterior approach (DAA) has become increasingly more popular for total hip arthroplasty (THA). Critics of the DAA maintain that a higher complication rate exists; however, data collection is prone to bias as the outcome is collected by the surgeons performing either an anterior or posterior approach (PA). This study aims to compare the short-term outcomes, including complication rates, in a Medicare population between THAs performed via DAA and PA. MATERIALS AND METHODS: Baseline patient data was obtained from our institution's database for bundled payments, an unbiased collection source. A retrospective chart review was conducted on 492 Medicare patients who underwent primary THA between October 2016 and September 2017 to separate patients into DAA and PA cohorts. Descriptive patient characteristics along with surgical and clinical data were collected. Statistical tests for significance were based on either t-tests or chi-squared. To control for demographic variables, a multivariable regression analysis was conducted. RESULTS: Two hundred forty-one patients were included in the DAA cohort while 251 were included in the PA cohort. Surgical time (74.39 vs. 103.03 minutes; p < 0.001) and length-of-stay (1.29 vs. 2.74 days; p < 0.001) in patients who underwent the DAA was revealed to be statistically lower compared to the PA cohort. Patients in the DAA cohort were statistically more likely to be discharged to home health agencies (HHA) or self-care compared to those in the PA cohort (93.4% vs.74.5%; p < 0.001). There were no statistical differences in 90-day readmission rates or morphine milligram equivalents per day between both cohorts. CONCLUSION: The DAA to THA resulted in shorter surgical time, length-of-stay, and increased likelihood of discharge to HHA or self-care when compared with the PA. There were no differences in opioid consumption and complications leading to 90-day readmission.

How Does Surgical Approach Affect Characteristics of Dislocation After Primary Total Hip Arthroplasty?

BACKGROUND: Concerns have been voiced regarding how surgical approach impacts risk of dislocation after total hip arthroplasty (THA). This study investigated how surgical approach impacts rate, direction, and timing of dislocations following THA. METHODS: We conducted a retrospective review of 13,335 primary THAs from 2011 to 2020 and identified 118 patients with prosthetic hip dislocation. Patients were stratified into cohorts by surgical approach used during primary THA. Patient demographics, index THA acetabular cup positioning, number, direction, timing of dislocations, and subsequent revisions were collected. RESULTS: Dislocation rate differed significantly between posterior approach (PA), direct anterior approach (DAA), and laterally-based approach (LA) (1.1 versus 0.7% versus 0.5%, P = .026). Rate of hips dislocating anteriorly was lowest in the PA group (19.2%) compared to LA (50.0%) and DAA groups (38.2%, P = .044). There was no difference in rate of hips dislocating posteriorly (P = .159) or multidirectional (P = .508) instability; notably 58.8% of dislocations in the DAA cohort occurred posteriorly. There were no differences in dislocation timing or revision rate. Acetabular anteversion was highest in the PA cohort compared to DAA and LA (21.5 versus 19.2 versus 11.7 degrees, P = .049). CONCLUSION: After THA, patients in the PA group had a slightly higher dislocation rate compared to the DAA and LA groups. The PA group had a lower rate of anterior dislocation and nearly 60% of DAA dislocations occurred posteriorly. However, with no differences in other parameters including revision rates or timing, our data suggests surgical approach may impact dislocation characteristics to a lesser degree than previous studies have suggested.

Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes?

BACKGROUND: Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success. METHODS: We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months. RESULTS: After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant. CONCLUSION: Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.

Are we getting better at cementing femoral stems in total hip arthroplasty? A 5-year institutional trend.

INTRODUCTION: Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or abnormal anatomy. We radiologically evaluated the quality of the femoral cement mantle in patients undergoing THA to examine whether cementation quality improved with increased institutional experience. METHODS: A retrospective study of 542 primary elective THAs performed using cemented stems from 2016 to 2021 at a high-volume orthopedic specialty center was conducted. Immediate post-operative anterior-posterior (AP) and lateral radiographs were evaluated to assess cement mantle quality based on the Barrack classification. Cement mantles were deemed satisfactory (Barrack A and B) or unsatisfactory (Barrack C and D). Regression was performed to identify predictors of unsatisfactory cementation quality. RESULTS: The annual cemented primary THA volume increased throughout the study period from 14 cases in 2016 to 201 cases in 2021. Overall, the majority of cement mantles were deemed satisfactory; 91.7% on AP radiographs and 91.0% on lateral radiographs. Satisfactory cementation on AP radiograph achievement rates improved during the study period, which coincided with greater annual volume (p < 0.001). No association was found between posterior and direct anterior surgical approaches and satisfactory cementation quality on both AP and lateral radiographs. CONCLUSION: Majority of femoral stems had satisfactory cementation quality. Higher institutional annual cemented THA volume was associated with improved cementation quality. Residency and fellowship training programs should place greater emphasis on the importance of femoral stem cementation for appropriately indicated patients. LEVEL OF EVIDENCE: III, retrospective cohort study.

Role of Operating Room Size on Air Quality in Primary Total Hip Arthroplasty.

BACKGROUND: Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Our study examines the role of OR size on air quality and ABP count in primary total hip arthroplasty (THA). METHODS: We analyzed primary THA procedures done within 2 ORs measuring 278 ft2 and 501 ft2 at a single academic institution from April 2019 to June 2020. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-squared test. RESULTS: A total of 116 primary THA cases were included: 18 (15.5%) in the "small" OR and 98 (84.5%) in the "large" OR. Between-group comparisons revealed significant differences in temperature (small OR: 20.3 ± 1.23 C versus large OR: 19.1 ± 0.85 C, P < .0001) and relative humidity (small OR: 41.1 ± 7.24 versus large OR: 46.9 ± 7.56, P < .001). Significant percent decreases in ABP rates for particles measuring 2.5 um (-125.0%, P = .0032), 5.0 um (-245.0%, P = .00078), and 10.0 um (-413.9%, P = .0021) were found in the large OR. Average time spent in the OR was significantly longer in the large OR (174 ± 33 minutes) compared to the small OR (151 ± 14 minutes) (P = .00083). CONCLUSION: Temperature and humidity differences and significantly lower ABP counts were found in the large compared to the small OR despite longer average time spent in the large OR, suggesting the filtration system encounters less particle burden in larger rooms. Further research is needed to determine the impact this may have on infection rates.

Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty.

BACKGROUND: Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. METHODS: We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests. RESULTS: Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001). CONCLUSION: Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. LEVEL III EVIDENCE: Retrospective Cohort Study.

Short-term outcomes of thin highly cross-linked polyethylene liners in primary total hip arthroplasty.

INTRODUCTION: The use of thin highly cross-linked polyethylene (HXLPE) liners in total hip arthroplasty (THA) allows utilisation of larger femoral heads. However, concern surrounding postoperative complications remains. This study aims to investigate rates of revision and re-admission associated with thin HXLPE liners at short-term follow-up. METHODS: We retrospectively reviewed 3047 patients who underwent THA with a cementless modular acetabular implant with a 36-mm femoral head, and different thicknesses of HXPLE liners from 2011 to 2021. We identified 723 patients (23.7%) with a minimum 2-year follow-up and 206 patients (6.8%) with a minimum 5-year follow-up. Patients in the thin group (TG, n = 1020) received <5.1-mm liners with 52-mm size cups while patients in the non-thin group (NTG, n = 2027) received >5.1-mm liners with >52-mm size cups. Outcomes were compared using multi-variable logistic regressions while controlling for all significant demographic differences. RESULTS: We found no significant differences in re-admission (3.9% vs. 4.3%, OR 0.97; 95% CI, 0.63-1.49; p = 0.874) and revision (2.5% vs. 3.2%, OR 0.72; 95% CI, 0.41-1.26; p = 0.246) rates between groups. The difference in fracture rate between groups was not significant, but the 1 recorded acetabular fracture (5%) occurred in the NTG. Although the rate of liner exchange was lower in the TG (1.1%) compared to the NTG (2.3%), the difference was not statistically significant (OR 0.51; 95% CI, 0.24-1.05; p = 0.068). Liners were exchanged for liner wear in 1 hip (1%), aseptic reasons in 38 hips (66%), and peri-prosthetic joint infection in 19 hips (33%). CONCLUSIONS: Patients undergoing THA with a thin liner were not significantly predisposed to higher rates of revision surgery or poorer clinical outcomes at short-term follow-up when compared to those who received a thicker liner. Consequently, further long-term studies regarding the utility of thin HXLPE implants in reducing complications should be pursued.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty.

BACKGROUND: Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIM: To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA. METHODS: We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients' preoperative status using hierarchical Poisson and linear regressions, respectively. RESULTS: There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15. CONCLUSION: All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

Similar Outcomes Achieved Between Anterior and Posterior Approach Total Hip Arthroplasty Using Dual Mobility Implants.

Background: Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants. Methods: We retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions. Results: Of the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups. Conclusion: Comparable outcomes following implantation of DM constructs may be achievable irrespective of the surgical approach employed. The incidence of iliopsoas injections for groin pain did not significantly differ between anterior and posterior approaches. Future investigation is needed to determine whether surgical approach influences long-term outcomes in patients receiving DM implants. Level of Evidence: III.

Validation of Single-Outcome Questionnaire in Primary TKA and THA.

BACKGROUND: Patient-reported outcome measures can be used to evaluate post-operative health care quality and patient satisfaction. The Patient's Joint Perception (PJP) question gathers a single patient-reported outcome to measure how patients appraise their joint. This study compares PJP to the Forgotten Joint Score (FJS) at 21 months post-operation to assess its value. METHODS: A retrospective review was performed at an orthopedic specialty hospital for patients who completed both PJP and FJS questionnaires in 2020-2021 and underwent either a unilateral elective primary Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA). Spearman's correlation coefficients and P-values were calculated to determine external validity of PJP. Floor and ceiling effects were analyzed and considered present if ≥ 15% of patients achieved the worst or best score (0-4 for PJP and 0-100 for FJS). RESULTS: In total, 534 patients (327 THA and 207 TKA) were surveyed at 21 months post-operation. External validity against FJS was assessed for both TKA (r = 0.66, P < .01) and THA (r = 0.69, P < .01). For TKA, the floor and ceiling effects were 0.97% and 25.12% for PJP and 3.86% and 4.83% for FJS, respectively. For THA, the floor and ceiling effects were 0.92% and 50.46% for PJP and 2.47% and 20.50% for FJS, respectively. CONCLUSION: The PJP was correlated with FJS moderately for both TKA and THA and can be collected with lesser burden. However, ceiling effects were higher in both TKA and THA for PJP compared to FJS. Further studies are needed to investigate the questionnaires at additional time points and to evaluate the implications of high ceiling effects.

The Forgotten Joint Score patient-acceptable symptom state following primary total hip arthroplasty.

AIMS: The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient's satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA. METHODS: We retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value. RESULTS: This study included 780 patients. The mean one-year FJS-12 score was 65.42 (SD 28.59). The mean one-year HOOS, JR score was 82.70 (SD 16.57). A high positive correlation between FJS-12 and HOOS, JR was found (r = 0.74; p<0.001), making the HOOS, JR a valid external anchor. The threshold score of the FJS-12 that maximized the sensitivity and specificity for detecting a PASS was 66.68 (area under the curve = 0.8). The cut-off score value computed with the 75th percentile approach was 92.20. CONCLUSION: The PASS threshold for the FJS-12 at one year following primary THA was 66.68 and 92.20 using the ROC curve and 75th percentile approaches, respectively. These values can be used to achieve consensus about meaningful postoperative improvement to maximize the utility of the FJS-12 to evaluate and counsel patients undergoing THA. Cite this article: Bone Jt Open 2022;3(4):307-313.

The direct anterior approach to the hip: a useful tool in experienced hands or just another approach?

The direct anterior approach (DAA) to the hip was initially described in the nineteenth century and has been used sporadically for total hip arthroplasty (THA). However, recent increased interest in tissue-sparing and small incision arthroplasty has given rise to a sharp increase in the utilization of the DAA. Although some previous studies claimed that this approach results in less muscle damage and pain as well as rapid recovery, a paucity in the literature exists to conclusively support these claims. While the DAA may be comparable to other THA approaches, no evidence to date shows improved long-term outcomes for patients compared to other surgical approaches for THA. However, the advent of new surgical instruments and tables designed specifically for use with the DAA has made the approach more feasible for surgeons. In addition, the capacity to utilize fluoroscopy intraoperatively for component positioning is a valuable asset to the approach and can be of particular benefit for surgeons during their learning curve. An understanding of its limitations and challenges is vital for the safe employment of this technique. This review summarizes the pearls and pitfalls of the DAA for THA in order to improve the understanding of this surgical technique for hip replacement surgeons.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge.

BACKGROUND: Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations. METHODS: We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables. RESULTS: Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131). CONCLUSION: Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system. LEVEL III EVIDENCE: Retrospective Cohort Study.

A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study.

BACKGROUND: Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS: We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS: Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ. CONCLUSION: Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care. LEVEL III EVIDENCE: Retrospective Cohort Study.

Impact of Preoperative Anemia Severity on Primary Total Hip Arthroplasty Outcomes.

BACKGROUND: Preoperative anemia (POA) is a significant predictor for adverse outcomes in primary total hip arthroplasty (THA). Current literature has studied POA stratified by severity. This study aims to find a threshold preoperative hemoglobin (Hb) value for increased risk of adverse outcomes in THA. METHODS: This is a retrospective analysis of primary THA patients with preoperative Hb values from 2014 to 2021 from an academic orthopedic specialty hospital. Demographics, surgical data, and postoperative outcomes were collected. Patients without preoperative Hb values within the electronic health record system or values acquired >30 days preoperatively were excluded. Patients were grouped based on POA severity using World Health Organization criteria. Secondary analysis using discrete preoperative Hb values was performed. P-values were calculated using analysis of variance/Kruskal-Wallis and chi-squared/Fisher's exact testing with P < .05 considered significant. RESULTS: A total of 1347 patients were included: 771 (57.2%) patients with POA and 576 (42.8%) with normal preoperative Hb. In the POA group, 292 (37.9%) were mild, 445 (57.7%) moderate, and 34 (4.4%) severe. Increased length of stay was seen in moderate (3.9 ± 4.3 vs 2.4 ± 2.1, P < .001) and severe (5.0 ± 3.4 vs 2.4 ± 2.1, P < .0001) groups compared to control. The severe group had higher 90-day readmission and revision rates compared to control. Analysis by discrete Hb values showed increased length of stay in Hb values <11 g/dL and a greater proportion of patients with Hb values <12 g/dL were discharged to skilled nursing facilities. CONCLUSION: Patients with preoperative Hb <12 g/dL should be assessed for other risk factors that may predispose them to postoperative complications. Further investigation is warranted to develop more robust perioperative management strategies for POA patients undergoing THA. LEVEL III EVIDENCE: Retrospective Cohort Study.