Preoperative Education Prior to Hip or Knee Arthroplasty Is Associated With Home Discharge but Not Reduced Length of Stay.

Background: Increasing numbers of patients are undergoing total joint arthroplasty as a treatment for osteoarthritis, which can be an anxiety-provoking experience. Setting expectations through a preoperative physical therapy (pre-op PT) session can alleviate some of these stressors, potentially decrease hospital length of stay (LOS), and promote home discharge. Purpose: We sought to determine whether attending a pre-op PT session is associated with decreased hospital LOS and home discharge in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. Methods: A retrospective cohort study was performed of 20,822 patients who underwent THA or TKA between January 2020 and December 2023. Pre-op PT attendance and covariates, including patient demographics and clinical data, were collected and analyzed for association with LOS and discharge disposition. Results: Unadjusted univariate analysis revealed that THA and TKA patients who received pre-op PT had a significantly lower average LOS and were more likely to be discharged home. Our multivariate regression model showed that pre-op PT was not significantly associated with LOS in both groups but was significantly associated with home discharge among THA patients. Conclusions: Our retrospective study of the effect of pre-op PT education on LOS and discharge disposition for elective THA and TKA patients found different results in univariate and multivariate analysis. Further study is needed to confirm the association found on multivariate analysis between pre-op PT and home discharge in THA patients.

Prone vs Supine Positioning for Femoral Derotation Osteotomy: Kinematic and Physical Examination Outcomes Suggest Both Can Achieve Desired Results.

Background: Femoral derotation osteotomy (FDO) for correction of internal rotation gait resulting from cerebral palsy (CP) can be performed with the patient in the prone or supine position. It is not known whether patient positioning during FDO affects the change in hip rotation. Purpose/Questions: We sought to compare the change in hip rotation following FDO performed on patients with CP in the prone or supine position through kinematic analysis. Methods: We conducted a consecutive retrospective cohort study of children with CP, ages 3 to 18 years and with Gross Motor Function Classification System (GMFCS) levels I to III, who underwent prone or supine FDO and pre- and postoperative motion analysis. The prone group included 37 patients (68 limbs) between 1990 and 1995. The supine group included 26 patients (47 limbs) between 2005 and 2015. The groups were matched for gender, age, and GMFCS level. The primary outcome was hip rotation in degrees during stance phase. Secondary outcomes included temporal-spatial parameters, hip abduction, hip and knee extension, and hip and knee passive range of motion (ROM). Results: The prone group had more bilateral patients (100%) than the supine group (81%). The supine group underwent more concomitant procedures. There was no difference between the prone and supine groups in postoperative stance hip rotation; both groups had significantly improved stance hip rotation, step width, and hip rotation passive ROM, pre- to postoperatively. Prone patients had improved postoperative hip extension, pelvic tilt, velocity, and cadence. Conclusions: There was no significant different in stance hip rotation between supine and prone FDO groups. Advocates of prone positioning for FDO suggest it allows more accurate assessment of rotation. Supine positioning may be more convenient when additional procedures are required. Based on our findings, either approach can achieve the desired result.

Preoperative Physical Therapy Education Reduces Time to Meet Functional Milestones After Total Joint Arthroplasty.

BACKGROUND: As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty. QUESTIONS/PURPOSES: Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery? METHODS: Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively). RESULTS: The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups. CONCLUSIONS: Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS. LEVEL OF EVIDENCE: Level II, therapeutic study.

Prospective Randomized Trial of the Efficacy of Continuous Passive Motion Post Total Knee Arthroplasty: Experience of the Hospital for Special Surgery.

Conflicting evidence has created substantial controversy regarding the use of continuous passive motion (CPM) in the in-patient setting post total knee arthroplasty (TKA). A total of 109 patients were randomly assigned to two groups, CPM or no CPM, applied after TKA. All patients received the same physical therapy protocol (3 sessions per day), with the only exception being the CPM. Both groups had a knee flexion of 115° at 6 weeks and 120° at 3 months, with no significant differences (P=0.69 and P=0.41, respectively). Length of stay was significantly less for the group who did not receive CPM. The use of CPM had no clinically relevant benefits with respect to AROM, clinical outcomes or discharge disposition and was associated with a cost of $235.50 per TKA.

A computerized order entry system was adopted with high user satisfaction at an orthopedic teaching hospital.

BACKGROUND: Computerized provider order entry (CPOE) has been considered essential for the reduction of medical errors and increased patient safety. Assessment of staff perception regarding a CPOE system is important for satisfaction and adoption. Incorporation of user feedback can greatly improve the functionality of a system and promote user satisfaction. QUESTIONS/PURPOSES: This study aims to develop an informatics staff satisfaction survey instrument and to understand what components of computerized prescriber order entry (CPOE) contribute to staff satisfaction and its variability over time. METHODS: The 22-question survey was developed by a multidisciplinary group and focused on patient data including demographics, orders, medications, laboratory, and radiology data. The questions were designed to understand if clinicians (1) could easily access the information needed to properly take care of patients, (2) could act upon the information once acquired, (3) could obtain the information clearly, and (4) were alerted to potential errors. The survey was distributed just prior to "go-live," 6 and 12 months after go-live. Responses were given on a five-point Likert scale. RESULTS: The survey results post-implementation showed user satisfaction with CPOE. Satisfaction regarding the ease of obtaining orders, medication, and lab data had a significant improvement at 6 and 12 months post-implementation, p < 0.001. Satisfaction that the computerized order entry system provided information needed to take care of their patients improved, p < 0.01. At 1 year post-implementation, user satisfaction declined from 6 months earlier but still demonstrated an overall increase in satisfaction from pre-implementation. CONCLUSION: Compared prior to go-live, clinicians are satisfied or very satisfied across multiple spheres and multiple disciplines. At all time points, clinicians were able to obtain information required to take care of their patients. However, post-go-live, it was easier to obtain and act upon as well as more clear and understandable.

Proximal femoral varus rotation osteotomy in cerebral palsy: a prospective gait study.

This prospective study examined the kinematic and temporal/spatial effects of proximal femoral varus rotation osteotomy (VRO) on the gait of individuals with cerebral palsy from preoperative to 1-year postoperative status. Participants were a consecutive sample of 37 individuals (14 males, 23 females). The analysis consisted of three-dimensional kinematics, temporal/spatial measures, and functional status. A curve representing the difference between the preoperative and 12-month postoperative conditions was calculated for each joint motion. Ninety-five percent confidence intervals were calculated about the mean difference curves using a bootstrapping technique. VRO resulted in improved cosmesis and objective improvement in gait, including a statistically significant increase in hip external rotation and hip extension, a decrease in anterior pelvic tilt, and an increase in knee extension strength. The use of confidence bands to identify surgical outcomes with respect to kinematic variables has enormous value for patients and professionals. Long-term follow-up is needed to see if the aforementioned gains improve.