The Risk Assessment and Prediction Tool Is Less Accurate in Extended Length of Stay Patients Following Total Joint Arthroplasty.

BACKGROUND: Although preoperative risk assessment tools have been effective in predicting discharge disposition after total joint arthroplasty (TJA), studies reporting on discharge planning in extended length of stay (ELOS), >3 days, patients are lacking. The purpose of this study was to describe the predictive utility of the Risk Assessment and Prediction Tool (RAPT) for discharge disposition in ELOS patients. METHODS: Our study included 260 patients with LOS >3 days who underwent primary TJA between 2014 and 2016. Patients were separated into 3 cohorts, based on their RAPT score: low risk (9-12), medium risk (6-9), and high risk for discharge to a facility (1-6). Scores were compared among cohorts and correlated with discharge disposition for patients who stayed beyond 3 days. RESULTS: In ELOS, RAPT had a higher utility in predicting discharge disposition in the low-risk (76.5% to home) and high-risk (62.9% to facility) patient cohorts, while medium-risk patients (56.5% to home) were the least accurate. Responses that significantly correlated with discharge home included male gender (odds ratio [OR], 1.81; P < .05), ambulation without walking aids (OR, 2.94; P < .01) or a single-point cane (OR, 2.95; P < .0001), <1 community support visit per week preoperatively (OR, 1.86; P < .05), and having support from someone at home (OR, 3.43; P < .0001). CONCLUSION: The RAPT score in ELOS patients is better correlated with the low-risk and high-risk cohorts than in medium-risk patients. Conversely, medium-risk ELOS patients constituted 56.8% of our sample size, but only predicted 56.5% of discharge dispositions correctly. Future discharge disposition risk assessment tools are needed to stratify medium-risk patients.

Barbed sutures in total hip and knee arthroplasty: what is the evidence? A meta-analysis.

INTRODUCTION: Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures. METHODS: A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures. RESULTS: Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n = 290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n = 298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p < 0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p = 0.95) and for major complication was not significantly different (OR 2.94, p = 0.27). The overall mean savings including both THA and TKA was USD 298 per case. CONCLUSIONS: In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures. LEVEL OF EVIDENCE: Level I.