Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch.

BACKGROUND: Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS: All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS: Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS: With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Conversion of Tibial Plateau Fractures to Total Knee Arthroplasty is Associated With Worse Patient-Reported Outcomes, Increased Operative Times, and Increased Complications.

BACKGROUND: Prior open reduction and internal fixation (ORIF) of tibial plateau fracture (TPF) adds complexity to subsequent total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of patients undergoing a TKA following prior ORIF of TPF to patients undergoing a primary TKA for osteoarthritis and an aseptic revision TKA. METHODS: There were 52 patients who underwent primary TKA following prior ORIF of TPF between January 2009 and June 2021, who were included and matched in a 1:4 ratio to 208 patients undergoing primary TKA. A second 1:1 matched comparison to 52 aseptic revision TKA patients was also included. The Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were obtained preoperatively and at two years postoperatively. Independent t-tests and Chi-square tests were used for statistical comparisons. RESULTS: The TPF patients were significantly younger than both primary and revision cohorts (55 ± 14.0 versus 63 ± 16.3 versus 64 ± 9.5, P < 0.001). Compared to primary TKA patients, the TPF group had worse Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores at two years (46.9 ± 18.5 versus 66.2 ± 17.8, P = 0.0152), higher rates of wound complications (15.4 versus 3.9%, P = 0.0020), and increased operative times (140.2 ± 45.3 versus 95.2 ± 25.7, P < 0.0001). Additionally, TPF patients were more likely to require a manipulation under anesthesia than both primary and revision patients (21.2 versus 5.8 versus 5.8%, P = 0.001). CONCLUSIONS: The TKAs following ORIF of TPF are more like revision TKAs than primary TKAs in terms of patient-reported outcomes, operative times, and wound complications. The rate of manipulation under anesthesia was higher than in both matched groups. These findings provide valuable information that can affect preoperative patient education and postoperative management regimens. They also emphasize the need for a conversion TKA code due to increased complexity and complications seen in this more difficult subset of TKAs.

John Charnley Award: A Quantitative Fluoroscopic Tool Improves Acetabular Fragment Positioning in Periacetabular Osteotomy.

BACKGROUND: Radiographic assessment of acetabular fragment positioning during periacetabular osteotomy (PAO) has been linked to hip survivorship. Intraoperative plain radiographs are time and resource intensive, while fluoroscopy can introduce image distortion affecting measurement accuracy. Our purpose was to determine whether intraoperative fluoroscopy-based measurements with a distortion correcting fluoroscopic tool improved PAO measurement targets. METHODS: We retrospectively reviewed 570 PAOs; 136 PAOs utilized a distortion correcting fluoroscopic tool, and 434 PAOs performed with routine fluoroscopy, prior to this technology. Lateral center-edge angle (LCEA), acetabular index (AI), posterior wall sign (PWS), and anterior center-edge angle (ACEA) were measured on preoperative standing radiographs, intraoperative fluoroscopic images, and postoperative standing radiographs. Defined target zones of correction were AI: 0-10°, ACEA: 25-40°, LCEA: 25-40°, PWS: negative. Postoperative correction in zones and patient-reported outcomes were compared using chi-square tests and paired t-tests, respectively. RESULTS: The average difference between postcorrection fluoroscopic measurements and 6-week postoperative radiographs was 0.21° for LCEA, 0.01° for ACEA, and -0.07° for AI (all P < .01). The PWS agreement was 92%. The percentages of hips meeting target goals overall improved with the new fluoroscopic tool: 74%-92% for LCEA (P < .01), 72%-85% for ACEA (P < .01), and 69 versus 74% for AI (P = .25), though there was no improvement in PWS (85 versus 85%, P = .92). All patient-reported outcomes except PROMIS Mental Health were significantly improved at most recent follow-up. CONCLUSIONS: Our study demonstrated improved PAO measurements and target goals with the use of a distortion correcting quantitative fluoroscopic real-time measuring device. This value-additive tool gives reliable quantitative measurements of correction without interfering with surgical workflow.