Patient Demographic Factors Affect Response Rates to Patient-Reported Outcome Measures for Total Hip Arthroplasty Patients.

INTRODUCTION: The Hip Disability and Osteoarthritis Outcome Score (HOOS JR) is a widely used patient-reported outcomes measures (PROMs) questionnaire for total hip arthroplasty (THA). However, not all patients choose to complete HOOS JR, and thus, a subset of the THA population may be underrepresented. This study aims to investigate the association between patient demographic factors and HOOS JR response rates. METHODS: This was a retrospective cohort study of adult, English-speaking patients who underwent primary THA by a fellowship-trained arthroplasty surgeon between 2017 and 2023 at a single, high-volume academic institution. The HOOS JR completion status-complete or incomplete-was recorded for each patient within 90 days of surgery. Standard statistical analyses were performed to assess completion against multiple patient demographic factors. RESULTS: Of the 2,908 total patients, 2,112 (72.6%) had complete and 796 (27.4%) had incomplete HOOS JR questionnaires. Multivariate analysis yielded statistical significance (P < 0.05) for the distribution of patient age, race, insurance, marital status, and income quartile with respect to questionnaire completion. Patient sex or religion did not affect response rates. Failure to complete HOOS JR (all P < 0.001) was associated with patients aged 18 to 39 (59.8%), who identified as black (36.4%) or "other" race (39.6%), were never married (38%), and were in the lower half income quartiles (43.9%, 35.9%) when compared to the overall incomplete rate. CONCLUSION: Multiple patient demographic factors may affect the HOOS JR response rate. Overall, our analyses suggest that older patients who identify as white and are of higher socioeconomic status are more likely to participate in the questionnaire. Efforts should focus on capturing patient groups less likely to participate to elucidate more generalizable trends in arthroplasty outcomes.

How Has the Total Hip Arthroplasty Patient Population Changed? A Ten-Year Analysis of Total Hip Arthroplasty Patients From 2013 to 2022: A Retrospective, Single-Center Study.

BACKGROUND: Over the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors. METHODS: We retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1, 2013, to December 31, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson comorbidity index, insurance, and socioeconomic status, as determined by median income by patients' zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test. RESULTS: Over the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = .001), BMI (2013: 29.0 to 2022: 29.5, P = .020), and mean Charlson comorbidity index (2013: 2.4 to 2022: 3.1, P = .001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = .001). The proportion of African American patients among the THA population increased from 11.3% in 2013 to 13.0% in 2022 (P = .012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = .107 and P = .136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < .001). CONCLUSIONS: In the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Impact of Obesity on the Forgotten Joint Score Following Primary Total Hip Arthroplasty.

BACKGROUND: Obesity is a growing public health concern. This study aims to identify the association of body mass index (BMI) on postoperative Forgotten Joint Score-12 (FJS-12) in patients undergoing primary total hip arthroplasty (THA). METHODS: We retrospectively reviewed 2130 patients at a single urban, academic, tertiary institution who underwent primary THA from 2016-2020 with available postoperative FJS-12 scores. Patients were stratified into two groups based on their BMI (kg/m2):<30 (nonobese) and ≥30 (obese). FJS-12 scores were collected postoperatively at 3 months, 1 year, and 2 years. Demographic differences were assessed with chi-square and independent sample t-tests. Mean scores between the groups were compared using multilinear regression analysis, controlling for demographic differences. RESULTS: Of the 2130 patients included, 1378 were nonobese, and 752 were obese. Although obese patients reported lower FJS-12 scores all time periods, there were no statistical differences between the two groups at 3 months (53.61 vs 49.62;P = .689), 1 year (68.11 vs 62.45; P = .349), and 2 years (73.60 vs 65.58; P = .102). A subanalysis comparing patients who were of normal BMI (<25), overweight (25.0-29.9), and obese (≥30) followed a similar inverse trend in scores but showed no statistical differences at all postoperative time points (3m:P = .612,1y:P = .607,2y:P = .253). Mean improvement in FJS-12 scores from 3 months to 1 year (14.50 vs 12.83; P = .041), 1 year to 2 years (5.49 vs 3.13; P = .004), and from 3 months to 2 years (20.00 vs15.96; P < .001) were significantly greater for nonobese patients compared to obese patients. CONCLUSION: While obesity trended toward lower FJS-12 scores, the differences in scores were not statistically significant compared to nonobese patients. BMI did not influence overall FJS-12 scores; however, obese patients achieved a slightly smaller statistical improvement during the first 2 years, though this may not be clinically significant. LEVEL III EVIDENCE: Retrospective Cohort Study.

Robotics Versus Navigation Versus Conventional Total Hip Arthroplasty: Does the Use of Technology Yield Superior Outcomes?

BACKGROUND: The use of technology such as navigation and robotic systems may improve the accuracy of component positioning in total hip arthroplasty (THA), but its impact on patient-reported outcome measures (PROMs) remains unclear. This study aims to elucidate the association between the use of intraoperative technology and PROMs in patients who underwent primary THA. METHODS: We retrospectively reviewed a consecutive series of patients who underwent primary THA between 2016 and 2020 and answered PROM questionnaires. Patients were separated into 3 groups depending on intraoperative technology utilization: computer-assisted navigation, robotic-assisted, or no technology (conventional) THA. Forgotten Joint Score-12 and Hip disability and Osteoarthritis Outcome Score, Joint Replacemen scores were collected at various time points. Demographic differences were assessed with chi-square and analysis of variance. Mean scores between groups were compared using univariate analysis of covariance, controlling for all significant demographic differences. RESULTS: Of the 1960 cases identified, 896 used navigation, 135 used robotics, and 929 used no technology. There were significant statistical differences in one-year Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores (85.23 vs 85.95 vs 86.76, respectively; P = .014) and two-year Forgotten Joint Score-12 scores (64.72 vs 73.35 vs 74.63, respectively; P = .004) between the 3 groups. However, these differences did not exceed the mean clinically important differences. Length of stay was statistically longest for patients who underwent conventionally performed THA versus navigation and robotics (2.22 vs 1.46 vs 1.91, respectively; P < .001). Surgical time was significantly longer for cases performed using robotics versus navigation and conventionally (119.61 vs 90.35 vs 95.35, respectively; P < .001). CONCLUSION: Statistical differences observed between all modalities are not likely to be clinically meaningful with regard to early patient-reported outcomes. Although intraoperative use of technology may improve the accuracy of implant placement, these modalities have not yet translated into improved early reported functional outcomes. LEVEL III EVIDENCE: Retrospective cohort.

Outcomes of Same-Day Discharge After Total Hip Arthroplasty in the Medicare Population.

BACKGROUND: There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. METHODS: A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. RESULTS: The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. CONCLUSION: The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

BACKGROUND: Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS: All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS: One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION: Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes.

BACKGROUND: Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS: A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS: No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION: The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Outpatient Total Hip Arthroplasty Has Minimal Short-Term Complications With the Use of Institutional Protocols.

BACKGROUND: Interest in outpatient/same-day discharge (SDD) total hip arthroplasty (THA) has been increasing over the last several years. There is considerable debate in the literature regarding the complication and readmission rates of these patients. To evaluate and validate the safety and efficacy of our institutional SDD THA care pathway, we compared the outcomes of patients undergoing SDD THA with patients who had a similar comorbidity profile and underwent inpatient THA. METHODS: A retrospective review was conducted on 164 patients who underwent SDD THA from January 2015 to September 2016. The Risk of Readmission Tool, a validated risk stratification instrument, was applied to all inpatient THAs performed from June 2014 to December 2016. A cutoff Risk of Readmission Tool score < 3 was used to produce a cohort of 1858 inpatient THA patients, all of whom had a similar risk profile to patients who underwent SDD THA. Medicare patients were excluded from the inpatient THA cohort, which left a final inpatient sample of 1315 patients. Each cohort was evaluated for demographic variables, length of stay, 30-/90-day readmissions, and discharge disposition. RESULTS: The SDD THA cohort had significantly lower body mass index (26.9 vs 28.2 kg/m2; P = .002), had fewer minorities (89.6% vs 66.3% Caucasians; P < .001), was exclusively commercial insurance (100% vs 36.3%), had a shorter length of stay (0.37 vs 2.3 days, P < .001), and was exclusively discharged home (100% vs 92.6%). There was no statistically significant difference in 30-day readmission rates between either cohort (SDD 0.6% vs inpatient 1.6%; P = .325). However, the SDD cohort had a significantly lower rate of 90-day readmissions than the inpatient cohort (0.6% vs 3.6%; P = .014). CONCLUSION: The use of an institutional SDD THA care pathway can produce results with equivalent or better short-term outcomes than that of traditional inpatient THA.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur.

BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.