Failed Same-Calendar-Day Discharges: Understanding the Reasons for an Inpatient Stay Following Intended Outpatient Total Joint Arthroplasty.

BACKGROUND: The adoption of Same-Calendar-Day discharge, or outpatient, arthroplasty has driven the evolution of care pathway protocols to optimize success rates of discharging patients home on the day of surgery. There are, however, instances where patients are unable to discharge on the same day as intended and require a stay in the hospital. This can lead to a poorer patient and provider care experience as well as incur additional costs. This study, therefore, aimed to determine the incidence of "failed" Same-Calendar-Day discharge, report the demographics of this patient population, and identify common reasons for failure of Same-Calendar-Day discharge. METHODS: A retrospective review of a prospectively maintained regional database of 1,002 Same-Calendar-Day discharge hip and knee arthroplasty patients was performed. Patients not discharged on the Same-Calendar-Day were converted to an Enhanced Recovery After Surgery (ERAS) pathway. The ERAS conversion cohort (n = 59) was identified, and demographics, comorbidities, and reasons for conversion were reported. RESULTS: Of 1,002 patients in the database, 59 (5.9%) did not achieve Same-Calendar-Day discharge. The most common comorbidities were hypertension (52.5%), arthritis of the spine (22.0%), and depression and anxiety (18.6%). The median length of stay for these patients was 1 night. The all-cause 90-day readmission rate of this patient group was 5.1%. Difficulty mobilizing (n = 16), nausea and vomiting (n = 14), and social circumstances (n = 11) were the primary causes of patients being converted to ERAS pathways. CONCLUSIONS: Same-Calendar-Day discharge arthroplasty can be successfully achieved in the majority of the patient group, provided patients are assessed and treated under standard protocols that are adapted to the individual needs. Common hurdles encountered in Same-Calendar-Day discharge arthroplasty are mobilization, nausea and vomiting, and social circumstances.

A Posteromedial Portal Allows Access to the Posteromedial Knee, While a Posterolateral Portal Risks Common Fibular Nerve Injury: A Cadaveric Analysis.

Purpose: To investigate the safety and accessibility of direct posterior medial and lateral portals into the knee. Methods: This study was a controlled laboratory study that comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16 mm from the vertical plane between the medial epicondyle of the femur and the medial condyle of the tibia, and 8 (females) and 14 mm (males) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension, and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen knees in 90 degrees of flexion. The posterior aspects of the knees were dissected from superficial to deep to assess potential damage caused by the cannula insertion. Results: The incidence of neurovascular damage was 9.6% (n = 10): 0.96% for the medial cannula and 8.7% for the lateral cannula. The medial cannula damaged 1 small saphenous vein (SSV). The lateral cannula damaged 1 SSV, 7 common fibular nerves (CFNs), and both the CFN and lateral cutaneous sural nerve in 1 specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens. Conclusions: A direct posterior portal into the knee with reference to the medial bony landmarks of the knee proved safe in 99% of the cadaveric sample and allowed access to the posterior horn of the medial meniscus. A direct posterior portal with reference to the lateral bony landmarks demonstrated a higher risk of neurovascular damage in the embalmed sample but no damage in the fresh-frozen sample. Given the severe consequences of common fibular nerve injury, recommending this approach at this stage is not advisable. Clinical Relevance: Direct posterior arthroscopy portals are understudied but may allow safe visualization of the posterior knee compartments and may also assist to manage repair of ramp lesions and posterior meniscus pathology.

Defining the popliteal fossa by bony landmarks and mapping of the courses of the neurovascular structures for application in popliteal fossa surgery.

Surgical access to the posterior knee poses a high-risk for neurovascular damage. The study aimed to define the popliteal fossa by reliable bony landmarks and comprehensively mapping the neurovascular structures for application in posterior knee surgery. Forty-five (20 male, 25 female) embalmed adult cadaveric knees were included. The position of the small saphenous vein (SSV), medial cutaneous sural nerve (MCSN) and lateral cutaneous sural nerv (LCSN), tibial nerve (TN) and common fibular nerve (CFN) nerves, and popliteal vein (PV) and popliteal artery (PA) were determined in relation to either medial (MFE) or lateral (LFE) femoral epicondyles, medial (MTC) and lateral (LTC) tibial condyles and the midpoint between the MFE and MTC and LFEF and LTC. The distance between the MFE and the PA, PV, TN, MCSN, and SSV was 38.4±12.1 mm, 38.4±12.9 mm, 39.4±10.2 mm, 39.2±14.0 mm and 37.6±12.5 mm respectively for males and 34.6±4.9 mm, 32.8±5.6 mm and 38.0±8.1 mm 38.8±10.1 mm and 37.9±8.2 mm respectively for females. The distance between LFE and the CFN and LCSN was 13.4±8.2 mm and 24.9±7.3 mm respectively for males and 8.4±9.1 mm and 18.4±10.4 mm respectively in females. This study defined the popliteal fossa by reliable bony landmarks and provided a comprehensive map of the neurovascular structures and will help to avoid injuries to the important neurovascular structures.

The determination of safe zones for arthroscopic portal placement into the posterior knee by mapping the courses of neurovascular structures in relation to bony landmarks.

PURPOSE: Minimally invasive surgery in the posterior knee is high risk for iatrogenic injury to popliteal neurovascular neurovasculature structures. This study aimed to use reliable landmarks to define safe zones for arthroscopic portal placement into the posterior knee. METHODS: Distances were measured between bony landmarks and neurovascular structures within the popliteal fossa using 45 formalin-embalmed cadavers: small saphenous vein (SSV), medial (MCSN) and lateral (LCSN) cutaneous sural nerves, tibial nerve (TN), common fibular nerve (CFN), popliteal vein (PV) and artery (PA). The structures were measured in relation to medial (MEF) and lateral (LEF) femoral epicondyle, medial (MCT) and lateral (LCT) tibial condyle and the midpoint between the landmarks. RESULTS: The mean distance (mm) between MEF and structures was, male and female, respectively: SSV 37.6 + 12.5, 37.9 + 8.2; MCSN 39.2 + 14, 38.8 + 10.1; TN 39.4 + 10.2, 38.0 + 8.1; PV 38.4 + 12.9, 32.8 + 5.6; PA 38.4 + 12.1, 34.6 + 4.9. At midpoint and MCT all structures medialized between 5 and 28%. The mean distance between LEF and structures was, male and female, respectively: CFN 13.4 + 8.2, 8.4 + 9.1; LCSN 24.9 + 7.3, 18.4 + 10.4. At midpoint and LCT the CFN lateralized by 37-42% and the LCSN medialized by 8-9%. CONCLUSIONS: Results suggest posteromedial portal placement can be safely established < 20 mm from the medial femoral epicondyle, tibial condyle or the midpoint between the two landmarks. Posterolateral portal placement is of higher risk, and entry point is 18 mm from the lateral femoral epicondyle, tibial condyle or the midpoint between the two landmarks in males and 12 mm in females. These landmarks will allow safe portal placement in 99% of cases.