Comparison of clinical outcomes of VISIONAIRE patient-specific instrumentation with conventional instrumentation in total knee arthroplasty: a systematic literature review and meta-analysis.

INTRODUCTION: Malalignment and resulting complications are major challenges in total knee arthroplasty (TKA) which patient-specific instrumentation (PSI) is proposed to alleviate. Previous PSI meta-analyses of TKA outcomes typically do not differentiate between PSI systems and assess relatively few outcomes, so the value of their findings is limited. VISIONAIRE™ cutting guides (Smith + Nephew Inc., Memphis, TN, USA) is a PSI system based on preoperative magnetic resonance and X-ray imaging. A systematic literature review (SLR) and meta-analysis, focussed specifically on VISIONAIRE, were conducted to assess TKA accuracy, intraoperative outcomes, and postoperative outcomes, compared with conventional instrumentation (CI). MATERIALS AND METHODS: The SLR was performed using PubMed, Embase, and Google Scholar databases to identify relevant studies published until March 2022. Depending on statistical heterogeneity, meta-analyses were performed for outcome measures with fixed effect (I2 < 50%) or random-effects models (I2 ≥ 50%). Dichotomous outcomes were reported as odds ratios and continuous outcomes were reported as mean differences. Descriptive analyses were performed for outcomes not amenable to meta-analysis. RESULTS: Outcomes for VISIONAIRE versus CI were reported in 25 studies. Compared with CI, VISIONAIRE reduced odds of mechanical outliers by 40% (p < 0.0001), with no statistically significant differences in odds of overall coronal, sagittal, or rotational plane component outliers. VISIONAIRE improved surgical efficiency (operating room, turnover, and tourniquet times reduced by 7.3% (p = 0.02), 42% (p = 0.022), and 15.9% (p = 0.01), respectively), lowering the odds of blood transfusion by 53% (p = 0.01) and shortening patients' hospital stays (11.1% reduction; p < 0.0001). There were no significant differences between groups in incidence of postoperative complications and (descriptively analyzed) return-to-function outcomes. CONCLUSION: Options for PSI in TKA differ substantially, and it is important to assess the outcomes of individual systems. The current findings suggest that VISIONAIRE guides can lead to improved alignment accuracy and surgical efficiency compared with CI, without compromising postoperative safety and return-to-function outcomes.

Bundled Payments for Care Improvement in the Private Sector: A Win for Everyone.

BACKGROUND: To help slow the rising costs associated with total joint arthroplasty (TJA), the Centers for Medicare and Medicaid Services introduced the Bundled Payments for Care Improvement (BPCI) initiative. The purpose of this study is to report our 1-year experience with BPCI in our 2 arthroplasty surgeon private practice. METHODS: In this series, a historical baseline group is compared with our first year under BPCI. We reviewed the cohorts with respect to hospital length of stay (LOS), readmission rates, discharge disposition, postacute care LOS, and overall savings on a per episode basis. RESULTS: The baseline group included 582 episodes from July 2009 to June 2012. The BPCI study group included 332 episodes from July 2015 to September 2016. We witnessed a substantial learning curve over the course of our involvement in the initiative. The total reduction in cost per episode for TJA was 20.0% (P = .10). Hospital LOS decreased from 4.9 to 3.5 days (P = .02). All-cause 90-day readmission rates decreased from 14.5% to 8.2% (P = .0078). Overall, discharges to home increased from 11.6% to 49.8% (P = .005). CONCLUSION: Our small, private, 2 arthroplasty surgeon orthopedic practice has shown improvement in postoperative management for TJA patients in 1 year under the BPCI initiative, with increased discharges to home, decreased skilled nursing admissions, days in skilled nursing, and overall readmissions. Because BPCI includes fracture care arthroplasty, the model could be made more equitable if these patients were reimbursed a rate commensurate with their increased costs and risks.

Total Joint Arthroplasty in a Stand-alone Ambulatory Surgical Center: Short-term Outcomes.

For decades, the average hospital stay following total joint arthroplasty (TJA) has been getting shorter. The historical standard was several weeks of hospitalization, yet improvements in perioperative care have reduced the average length of stay to a few days. Medicare recognizes a 3-day inpatient stay as the standard of care following hip or knee replacement. Yet continued advances in minimally invasive surgical techniques, short-acting general anesthetics, long-acting local anesthetics, and blood loss management have further improved the safety and recovery for TJA procedures. Thus, further reductions in postoperative hospitalization have been implemented around the country, with surgeons reporting successful same-day protocols, as defined by hospitalization discharge on the day of surgery. Although these studies have presented results of same-day TJA in the hospital setting, this study is the first to report on the perioperative adverse events and early outcomes of 51 consecutive TJA procedures performed in a stand-alone ambulatory surgical center (ASC). The ASC offers an ideal setting to perform such procedures in the properly selected patient population, obviating any form of postoperative hospitalization. Although 16 (31.4%) of 51 patients reported minor adverse events in the postanesthesia care unit, specifically nausea and/or pain, early intervention permitted 50 (98.0%) of 51 patients to be discharged home, on average 176 minutes after surgery, with 1 patient discharged to a rehabilitation facility as arranged prior to surgery. There were no major adverse events in the 90-day perioperative period, and although 1 (2.0%) patient was hospitalized for persistent incisional drainage, none required admission for pain. This study examines the strict eligibility criteria and perioperative analgesia protocols that permit successful outpatient TJA. [Orthopedics. 2016; 39(4):223-228.].