Manipulation Under Anesthesia After Total Knee: Who Still Requires a Revision Arthroplasty?

BACKGROUND: Stiffness after total knee arthroplasty (TKA) is a multifactorial complication involving patient, implant, surgical technique, and rehabilitation, occasionally necessitating manipulation under anesthesia (MUA) or revision. Few modern databases contain sufficient longitudinal information of all factors. We characterized MUA after primary TKA and identified independent risk factors for revision TKA after MUA from the American Joint Replacement Registry. METHODS: We retrospectively reviewed primary TKAs for American Joint Replacement Registry patients ≥65 years from January 1, 2012 to 31 March, 2019. We linked these to the Centers for Medicare and Medicaid Services database to identify MUA and revision TKA procedure codes. We compared groups with chi-squared testing, identifying independent risk factors for subsequent revision with binary logistic regression presented as odds ratios with 95% confidence intervals. RESULTS: Of 664,604 primary TKAs, 3918 (0.6%) underwent MUA after a median of 2.0 ± 1.0 months. Revision surgery occurred in 131 (3.4%) MUA patients after a median of 9.0 months. Timing of MUA was not different between revision and no revision patients (P = .09). Patients undergoing MUA compared to no MUA were older (age 71.5 vs 70.7, P < .01), predominantly female (63.9% vs 61.2%, P < .01), current/former tobacco users (24.2% vs 13.3%, P < .01), with osteoarthritis diagnoses (98.0% vs 84.3%, P < .01). Independent risk factors for revision after MUA were male gender (1.56, 1.09-2.22). CONCLUSION: The incidence of MUA after primary TKA is low (0.6%) in Medicare patients ≥65 years of age; 3.4% progress to revision after a median of 9 months. Being male was significantly associated with revision TKA after MUA.

PROMIS PF correlates with HOOS, JR in patients with hip pain.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost. QUESTIONS: 1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures? METHODS: In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models. RESULTS: We found a large correlation between PROMIS PF and HOOS, JR (r 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [ß] -3.4; 95% confidence interval [CI] -5.8 to -1.0; P = 0.006 and ß -11; 95% CI -17 to -5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (ß 4.5; 95% CI 2.2 to 6.8; P < 0.001 and ß 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect. CONCLUSIONS: This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures. LEVEL OF EVIDENCE: Level III.

Enhanced Selection of Candidates for Same-Day and Outpatient Total Knee Arthroplasty.

BACKGROUND: Medicare removed total knee arthroplasty (TKA) from its inpatient-only list and private insurers created ambulatory surgical codes; these changes bring about logistical challenges for TKA episode planning. We identified preoperatively determined factors associated with hospital length of stay for (1) same-day discharge (SDD) and (2) inpatient TKA defined by Medicare's 2-midnight rule benchmark. METHODS: We retrospectively reviewed 325 consecutive unilateral primary TKAs performed on patients completing the Perioperative Surgical Home preoperative optimization pathway within a single hospital system. Stepwise logistic regression modeling was performed to identify preoperatively determined factors associated with (1) SDD and (2) inpatient TKA. We compared these models' ability to discern the length of stay category to the Risk Assessment and Prediction Tool (RAPT) score alone. RESULTS: The cohort included 32 (10%) SDD, 189 (58%) next-day discharges, and 104 (32%) inpatients. Lower body mass index (BMI; odds ratio [OR], 0.92; 95% CI, 0.85-0.1.0; P = .04) and fewer self-reported allergies (OR, 0.66; 95% CI, 0.46-0.95; P = .03) were associated with SDD. The SDD model outperformed the RAPT alone (C-statistic, 0.73 vs 0.52; P < .01). Older age (OR, 0.96; P = .04), higher BMI (OR, 0.93; P 0.01), lower RAPT score (OR, 1.2; P = .04), and later surgery start time (OR, 0.80; P < .01) were associated with inpatient discharge. The inpatient model outperformed the RAPT alone (C-statistic, 0.74 vs 0.62; P < .01). CONCLUSION: We identified preoperatively determined factors associated with (1) SDD as BMI and allergies and (2) inpatient TKA as age, BMI, RAPT score, and surgery start time. Hospitals, providers, patients, families, and payers can use this information for TKA episode planning.

Surgical hip dislocation through a modified direct lateral approach: real-time perfusion monitoring.

This study aimed to measure femoral head perfusion during hip resurfacing arthroplasty through a trochanter-sparing modified direct lateral approach. High-power laser Doppler probes were inserted into the femoral heads of 26 patients (26 hips, age range 35-70 years). Changes in blood flow were recorded (1) pre-capsulectomy (reference), (2) post-capsulectomy, and (3) following femoral head dislocation and reduction. There were no statistically significant changes in perfusion amplitudes post-capsulectomy and following femoral head dislocation and reduction (mean -10%, P = .134 and +27%, P = .166, respectively). Prolonged dislocation with the hip maximally flexed and externally rotated resulted in significantly decreased perfusion (mean -28%, P = .002). This study provides in vivo evidence that surgical hip dislocation is feasible using a modified direct lateral approach.

Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim.

BACKGROUND: Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience. METHODS: A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. RESULTS: In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient. CONCLUSION: TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

No Difference Between Low- and Regular-dose Aspirin for Venous Thromboembolism Prophylaxis After THA.

BACKGROUND: Aspirin is established as an effective prophylaxis for venous thromboembolism (VTE) after THA; however, there is no consensus as to whether low- or regular-dose aspirin is more effective at preventing VTE. QUESTIONS/PURPOSES: (1) Is there a difference in the incidence of symptomatic VTE within 90 days of elective THA using low-dose aspirin compared with regular-dose aspirin? (2) Is there a difference in the risk of significant bleeding (gastrointestinal and wound bleeding) and mortality between low- and standard-dose aspirin within 90 days after surgery? METHODS: We retrospectively evaluated 7488 patients in our database who underwent THA between September 2012 and December 2016. A total of 3936 (53%) patients received aspirin alone for VTE prophylaxis after THA. During the study period, aspirin was prescribed as a monotherapy for VTE prophylaxis after surgery in low-risk patients (no history of VTE, recent orthopaedic surgery, hypercoagulable state, history of cardiac arrhythmia requiring anticoagulation, or receiving anticoagulation for any other medical conditions before surgery). Patients were excluded if aspirin use was contraindicated because of peptic ulcer disease, intolerance, or other reasons. Patients received aspirin twice daily (BID) for 4 to 6 weeks after surgery and were grouped into two cohorts: a low-dose (81 mg BID) aspirin group (n = 1033) and a standard-dose (325 mg BID) aspirin group (n = 2903). The primary endpoint was symptomatic VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]). Secondary endpoints included significant bleeding (gastrointestinal [GI] and wound) and mortality. Exploratory univariate analyses were used to compare confounders between the study groups. Multivariate regression was used to control for confounding variables (including age, sex, body mass index, comorbidities, and surgeon) as we compared the study groups with respect to the proportion of patients who developed symptomatic VTE, bleeding (GI or wound), and mortality within 90 days of surgery. RESULTS: The 90-day incidence of symptomatic VTE was 1.0% in the 325-mg group and 0.6% in the 81-mg group (p = 0.35). Symptomatic DVT incidence was 0.8% in the 325-mg group and 0.5% in the 81-mg group (p = 0.49), and the incidence of symptomatic PE was 0.3% in the 325-mg group and 0.2% in the 81-mg group (p = 0.45). Furthermore, bleeding was observed in 0.8% of the 325-mg group and 0.5% of the 81-mg group (p = 0.75), and 90-day mortality was not different (0.1%) between the groups (p = 0.75). After accounting for confounders, regression analyses showed no difference between aspirin doses and the 90-day incidence of symptomatic VTE (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.29-2.85; p = 0.85) or symptomatic DVT (OR, 0.96; 95% CI, 0.26-3.59; p = 0.95). CONCLUSIONS: We found no difference in the incidence of symptomatic VTE after THA with low-dose compared with standard-dose aspirin. In the absence of compelling evidence to the contrary, low-dose aspirin appears to be a reasonable option for VTE prophylaxis in otherwise healthy patients undergoing elective THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Emergency Department Visits Within Thirty Days of Discharge After Primary Total Hip Arthroplasty: A Hidden Quality Measure.

BACKGROUND: Thirty-day hospital readmissions following total hip arthroplasty (THA) have received increasing scrutiny by policy makers and hospitals. Emergency department (ED) visits may not necessarily result in an inpatient readmission but can be a measure of performance and can incur costs to the health system. The purpose of this study is to describe the following: (1) the frequency and subsequent disposition; (2) patient characteristics; (3) reasons; and (4) potential risk factors for ED visits that did not result in a readmission within 30 days of discharge after THA. METHODS: All primary THAs performed at a large healthcare system between 2013 and 2015 were identified. Patients who received unplanned hospital services for complications within 30 days following surgery were identified and analyzed. A multiple regression analysis was utilized to identify risk factors predisposing for returning to the ED without readmission. RESULTS: From a total of 6270 primary THAs, 440 patients (7%) had an unplanned return to the hospital within 30 days. Of those, 227 (3.6%) patients presented to the ED and were not readmitted. Higher percentage of African Americans was noted among patients who returned to the ED versus those who did not (20.2% vs 9.8%, P < .01). The most common medical diagnoses were nonspecific medical symptoms (24.8%) followed by minor gastrointestinal problems (10.5%). The most common surgery-related diagnoses were pain and swelling (35%), followed by wound complications (12%) and hip dislocations (7.3%). Nearly 50% of wound complications and 40% of hip dislocations were managed and discharged from the ED without a readmission. Both African Americans (odds ratio 2.28, 95% confidence interval 1.55-3.36) and home discharge (odds ratio 1.90, 95% confidence interval 1.28-2.82) were independent risk factors for return to the ED without readmission. CONCLUSION: ED visits that do not result in hospital readmissions, many of which may be due to serious complications, are more frequent than inpatient readmission. This is extremely relevant to policy makers and quality metrics, especially as comprehensive and bundled payment initiatives become more prevalent.

Same-Day Bilateral Total Knee Arthroplasty Candidacy Criteria Decrease Length of Stay and Facility Discharge.

Simultaneous bilateral total knee arthroplasty (SBTKA) may present a higher risk for postoperative complications than unilateral surgery. The authors retrospectively identified 561 patients who underwent SBTKA between 2013 and 2015. The cohort was stratified according to the following appropriateness of care criteria (AOCC): (1) age younger than 70 years; (2) absence of cardiac disease; (3) controlled diabetes; and (4) body mass index less than 30 kg/m2. The authors created an AOCC score, with 0 representing the most ideal candidates and 4 representing the least ideal candidates. The cohort included 140 (25%) ideal candidates with a score of 0; the cohort also included 299 (53%) non-ideal candidates with a score of 1, 105 (19%) with a score of 2, 14 (2%) with a score of 3, and 3 (1%) with a score of 4. Ideal candidates had the shortest mean length of stay at 3.6±1.2 days. Length of stay was longer for patients with an AOCC score of greater than 2 compared with those with an AOCC score of 2 or less (5.2±4.3 vs 3.8±1.6 days, P<.001). Ideal candidates were discharged to home more often than other patients (26% vs 13%, P<.001). Although there was no difference in 90-day all-cause complications between ideal and non-ideal candidates (13% vs 16%, P=.400), medical complications trended strongly (6% vs 11%, P=.086). Appropriateness of care criteria for SBTKA patients were associated with shorter length of stay, higher rates of home discharge, and a trend toward lower complication rates. Simultaneous bilateral total knee arthroplasty can offer better outcomes in a subgroup of patients appropriately selected for surgery. Physicians can use these results to counsel their patients about risks and benefits of undergoing SBTKA. [Orthopedics. 2018; 41(5):293-298.].

Validation of a Novel Surgical Data Capturing System Following Total Hip Arthroplasty.

BACKGROUND: The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes. METHODS: This study includes data from the first 100 primary THAs and 100 revision THAs performed by 15 surgeons at a single institution from January through April 2016. Surgeons prospectively entered procedural details into OME following surgery. The OME database and operative notes were compared to evaluate completion rates and agreement. Completion rates were compared using McNemar's test (with continuity correction), while agreement was analyzed using Cohen's kappa (κ) and concordance correlation coefficient. RESULTS: The OME database had significantly higher completion rates for 41% (39/96) of the variables. Proportion of data points that matched between the operative notes and OME data revealed that 54% (52/96) had a proportion agreement >0.90, and 79% (76/96) had a proportion agreement >0.80. In regard to measured agreement, 25% (24/96) of variables had almost perfect agreement, 29% (28/96) had substantial agreement, and 14% (13/96) had moderate agreement. Only 4% (4/96) had fair agreement, 8% (8/96) had slight agreement, and 6% (6/96) had poor agreement. CONCLUSION: The OME data capture system is an efficient tool to document procedural details following THA. The system is user-friendly, comprehensive, and accurate. It has the potential to be a valuable tool for future orthopedic research.

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty.

BACKGROUND: Aspirin is an effective prophylaxis for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The optimal prophylactic aspirin dose has not been established. The study aims to compare 2 aspirin regimens with regard to the incidence of (1) symptomatic deep venous thrombosis (DVT), (2) pulmonary embolism (PE), (3) bleeding, and (4) mortality within 90 days after TKA. METHODS: We retrospectively identified 5666 patients who received aspirin twice daily for 4 to 6 weeks after TKA. A total of 1327 patients received 81-mg BID and 4339 patients received 325-mg BID aspirin. Postoperative complications collected were VTEs (DVT and PE), bleeding (gastrointestinal or wound bleeding), and mortality. RESULTS: The incidence of VTE was 1.5% in the 325-mg group and 0.7% in the 81-mg group (P = .02). Symptomatic DVT was 1.4% in the 325-mg aspirin compared with 0.3% for the 81-mg aspirin (P = .0009). Regression model showed no correlation between aspirin dose and VTE incidence (odds ratio [OR] = 1.03; 95% confidence interval [95% CI], 0.45-2.36; P = .94) or DVT (OR = 0.50; 95% CI, 0.16-1.55; P = .20). The incidence of PE was 0.2% in the high-aspirin group compared with 0.4% in the low-aspirin group (P = .13). Bleeding was 0.2% in the 325-mg aspirin group and 0.2% in the 81-mg aspirin group (P = .62), and 90-day mortality was similar (0.1%) between the groups (P = .56). CONCLUSION: Low-dose aspirin was not inferior to high-dose aspirin for the prevention of VTE after TKA. Low-dose aspirin can be considered a safe and effective agent in the prevention of VTE after TKA.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications.

BACKGROUND: Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. METHODS: A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. RESULTS: A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient. CONCLUSION: The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually.