Transition to outpatient total hip and knee arthroplasty: experience at an academic tertiary care center.

BACKGROUND: Interest in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) has increased recently as part of value-based care and early recovery protocols. Outpatient pathways require significant paradigm shifts, are not used widely, and are mostly implemented at outpatient surgery centers or orthopedic specialty hospitals. In this article, we report on the outcomes of implementation of an outpatient arthroplasty protocol at a tertiary care academic medical center. METHODS: We performed a retrospective review on a series of 105 consecutive patients who underwent THA or TKA following our newly implemented outpatient arthroplasty protocol. We compared these patients to a group of inpatient arthroplasty patients from the same time period. RESULTS: Eighty-three of 105 (79%) patients were successfully discharged home on the day of surgery. Successful same-day discharge was predicted by early ambulation (P = .01), TKA over THA (P = .04), and shorter duration of surgery (P = .01). General anesthesia correlated with better early ambulation distances (P = .03) and a lower incidence of urinary retention (P = .049). The outpatient readmission and complication rates were 0.95% and 1.9%, respectively, whereas the matched inpatient rates were 3.7% and 2.9%, respectively. CONCLUSIONS: Outpatient THA and TKA in a well-selected patient is feasible in an academic multidisciplinary tertiary care hospital, with complication rates approximating inpatient surgery. The findings reported here can be used to further optimize outpatient arthroplasty protocols.

Acute Kidney Disease After Total Hip and Knee Arthroplasty: Incidence and Associated Factors.

BACKGROUND: The development of acute kidney disease (AKD) following total joint arthroplasty has not been well characterized in the literature. We sought to calculate the incidence and identify risk factors associated with postoperative AKD for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A total of 1000 consecutive cases (860 unique patients, including revisions) of TKA or THA performed between January 2010 and May 2016 were identified. Seventy-nine cases were excluded due to pre-existing kidney dysfunction and 23 additional cases were excluded due to incomplete data, resulting in 898 cases included in the study. There were 492 females and 406 males with a mean age of 58.1 years (range, 14-93 years). The Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria and serum creatinine values were used to determine AKD status. Multiple logistic regression modeling was used to identify postoperative AKD risk factors. RESULTS: Overall incidence of postoperative AKD was 6.8% (n = 61). Use of perioperative angiotensin receptor blocker (ARBs) or angiotensin-converting enzyme inhibitors (ACEi) (odds ratio [OR] = 2.09; P = .030), increasing body mass index (BMI) (OR = 1.58 per 10 kg/m2; P = .014), and use of vancomycin perioperatively (OR = 1.91; P = .021) were associated with increased odds of development of postoperative AKD. CONCLUSION: A 6.8% incidence rate of postoperative AKD was noted in patients undergoing TKA or THA. Perioperative use of ARBs/ACEi, perioperative vancomycin use, and increased BMI were associated with increased odds of postoperative AKD.

Hyperfractionated radiotherapy with concurrent cisplatin/5-Fluorouracil for locoregional advanced head and neck cancer: analysis of 105 consecutive patients.

Objective. We reviewed a cohort of patients with previously untreated locoregional advanced head and neck squamous cell carcinoma (HNSCC) who received a uniform chemoradiotherapy regimen. Methods. Retrospective review was performed of 105 patients with stage III or IV HNSCC treated at Greater Baltimore Medical Center from 2000 to 2007. Radiation included 125 cGy twice daily for a total 70 Gy to the primary site. Chemotherapy consisted of cisplatin (12 mg/m(2)/h) daily for five days and 5-fluorouracil (600 mg/m(2)/20 h) daily for five days, given with weeks one and six of radiation. All but seven patients with N2 or greater disease received planned neck dissection after chemoradiotherapy. Primary outcomes were overall survival (OS), locoregional control (LRC), and disease-free survival (DFS). Results. Median followup of surviving patients was 57.6 months. Five-year OS was 60%, LRC was 68%, and DFS was 56%. Predictors of increased mortality included age ≥55, female gender, hypopharyngeal primary, and T3/T4 stage. Twelve patients developed locoregional recurrences, and 16 patients developed distant metastases. Eighteen second primary malignancies were diagnosed in 17 patients. Conclusions. The CRT regimen resulted in favorable outcomes. However, locoregional and distant recurrences cause significant mortality and highlight the need for more effective therapies to prevent and manage these events.

Comparison of acute toxicities in two primary chemoradiation regimens in the treatment of advanced head and neck squamous cell carcinoma.

PURPOSE: The optimal dosage and frequency of platinum-based chemoradiotherapy (CRT) regimen for treating advanced head and neck squamous cell carcinoma remains unresolved. This study aims to compare the toxicity and efficacy of weekly versus more dose-intensive cisplatin-based CRTs. METHODS: We reviewed 155 stage III/IV head and neck squamous cell carcinoma patients with no evidence of distant metastasis treated with one of two CRT regimens from 2000 to 2010 at Greater Baltimore Medical Center. Twice-daily radiation was provided as a split course over a 45-day period. Regimen A consisted of concomitant cisplatin (30 mg/m2/1 h) weekly for 6 cycles; regimen B consisted of concomitant cisplatin (12 mg/m2/1 h) and 5-fluorouracil (600 mg/m2/20 h) on days 1 through 5 and days 29 through 33. Main outcome measures included acute toxicities (myelosuppression, neurotoxicity, nephrotoxicity, gastrointestinal dysfunction), unplanned hospitalizations, and disease control at 12 months. RESULTS: Patients on regimen A were much less likely to experience ototoxicity due to their treatment (0% vs. 9.8%, P = 0.04). They were more likely to experience thrombocytopenia acutely (46% vs. 26%, P = 0.02), but the toxicity was not limiting (grade 1­2). No significant differences exist in the incidence of other toxicities or unplanned hospitalizations. At 1 year, 97% of patients on A vs. 86% of patients on regimen B were free of disease (P = 0.11). CONCLUSIONS: With concurrent radiotherapy, low-dose, single-agent, weekly cisplatin is less likely than higher-dose daily cisplatin plus 5-fluorouracil provided at the beginning and end of treatment to be associated with ototoxicity. The preliminary data suggest at least equivalent efficacy, but longer follow-up is required.