An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip and total knee arthroplasty. Methods: This retrospective study split patients into cohorts: TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following the resumption of elective surgeries (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index, American Society of Anesthesiologists score, and pertinent comorbidities were analyzed, and length of stay, 30-day emergency department (ED) visit rates, readmissions, and reoperations were compared. Results: A total of 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (interquartile range 63-76), and the post-COVID group had a median age of 68 years (interquartile range 61-75) (P = .024). SDD increased from 0.1% to 28.9% (P < .001), and length of stay decreased from 1.3 days to 0.89 days (P < .001). There was no change in 30-day ED visits, readmissions, or reoperations (P = .817, P = .470, and P = .643, respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P < .001, odds ratio [OR] = 0.94), body mass index (P = .006, OR = 0.95), male sex (P < .001, OR = 1.83), and history of tobacco use (P < .001, OR = 1.87). Conclusions: At our institution, the COVID-19 pandemic accelerated the utilization of SDD pathways without increasing ED visits, readmissions, or reoperations.

The feasibility of achieving Elective Care Framework targets for total hip arthroplasty and total knee arthroplasty in Northern Ireland.

AIMS: Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the NHS, which have been further lengthened by the onset of the COVID-19 global pandemic in March 2020. The Department of Health in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Mathematical modelling was undertaken to calculate when the ECF targets will be achieved for THA and TKA, as well as the time when waiting lists for THA and TKA will be cleared. The number of patients currently on the waiting list and percentage operating capacity relative to pre-COVID-19 capacity was used to determine future projections. RESULTS: As of May 2021, there were 3,757 patients awaiting primary THA and 4,469 patients awaiting primary TKA in Northern Ireland. Prior to April 2020, there were a mean 2,346 (2,085 to 2,610) patients per annum boarded for primary THA, a mean 2,514 (2,494 to 2,514) patients per annum boarded for primary TKA, and there were a mean 1,554 primary THAs and 1,518 primary TKAs performed per annum. The ECF targets for THA will only be achieved in 2030 if operating capacity is 200% of pre COVID-19 pandemic capacity and in 2042 if capacity is 170%. For TKA, the targets will be met in 2034 if capacity is 200% of pre-COVID-19 pandemic capacity. CONCLUSION: This modelling demonstrates that, in the absence of major funding and reorganization of elective orthopaedic care, the targets set out in the ECF will not be achieved with regard to THA and TKA. Waiting times for THA and TKA surgery in Northern Ireland are likely to remain greater than 52 weeks for most of this decade. Cite this article: Bone Jt Open 2022;3(4):302-306.

Implementation of an enhanced recovery protocol at a safety net hospital : a silver lining to COVID-19?

AIMS: This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. METHODS: A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. RESULTS: The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. CONCLUSION: Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a 'silver lining' to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871-878.

Spontaneous HIT syndrome: Knee replacement, infection, and parallels with vaccine-induced immune thrombotic thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is characterized clinically by thrombocytopenia, hypercoagulability, and increased thrombosis risk, and serologically by platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies. Heparin-"induced" acknowledges that HIT is usually triggered by a proximate immunizing exposure to heparin. However, certain non-heparin medications (pentosan polysulfate, hypersulfated chondroitin sulfate, fondaparinux) can trigger "HIT". Further, naturally-occurring polyanions (bacterial lipopolysaccharide, DNA/RNA) can interact with PF4 to recapitulate HIT antigens. Indeed, immunologic presensitization to naturally-occurring polyanions could explain why HIT more closely resembles a secondary, rather than a primary, immune response. In 2008 it was first reported that a HIT-mimicking disorder can occur without any preceding exposure to heparin or polyanionic medications. Termed "spontaneous HIT syndrome", two subtypes are recognized: (a) surgical (post-orthopedic, especially post-total knee arthroplasty, and (b) medical (usually post-infectious). Recently, COVID-19 adenoviral vector vaccination has been associated with a thrombotic thrombocytopenic disorder associated with positive PF4-dependent enzyme-immunoassays and serum-induced platelet activation that is maximal when PF4 is added. Vaccine-induced immune thrombotic thrombocytopenia (VITT) features unusual thromboses (cerebral venous thrombosis, splanchnic vein thrombosis) similar to those seen in spontaneous HIT syndrome. The emerging concept is that classic HIT reflects platelet-activating anti-PF4/heparin antibodies whereas spontaneous HIT syndrome and other atypical "autoimmune HIT" presentations (delayed-onset HIT, persisting HIT, heparin "flush" HIT) reflect heparin-independent platelet-activating anti-PF4 antibodies-although the precise relationships between PF4 epitope targets and the clinical syndromes remain to be determined. Treatment of spontaneous HIT syndrome includes non-heparin anticoagulation (direct oral Xa inhibitors favored over direct thrombin inhibitors) and high-dose immunoglobulin.

Current Practice Trends in Primary Hip and Knee Arthroplasties Among Members of the American Association of Hip and Knee Surgeons: An Update During the COVID-19 Pandemic.

At the hybrid 2020 Annual Meeting of the American Association of Hip and Knee Surgeons, an audience response poll was conducted to determine current practice patterns among its members. The poll was completed via a mobile application (ie, app) due to the COVID-19 pandemic, and allowed both in-person and virtual attendees to provide responses to multiple choice questions related to practice patterns pertaining to primary total hip arthroplasties and primary total knee arthroplasties. Moreover, results were compared to findings from previous polls.