In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study.

Purpose: Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH). Methods: Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer. Results: Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates. Conclusion: Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Use of the supercapsular percutaneously assisted total hip approach for femoral neck fractures: surgical technique and case series.

BACKGROUND: Femoral neck fractures are common injuries in the geriatric population associated with high morbidity and mortality rates. Studies have shown outcomes can be positively influenced by early postoperative mobilization. The supercapsular percutaneously assisted total hip (SuperPath) surgical technique has been shown to lead to early mobilization for osteoarthritic total hip replacement patients and as such has the potential to provide similar benefits in fracture patients. This manuscript provides a detailed description of this technique using hemiarthroplasty to treat femoral neck fractures and presents the first case series of this application. METHODS: Seventeen patients with femoral neck fractures managed with this technique at two separate institutions were reviewed. In an attempt to minimize blood loss and enhance early mobilization, hemiarthroplasty utilizing the SuperPath technique was performed. The authors noticed decreased blood loss, operative time, and postoperative narcotic usage when compared to their previous experiences using traditional techniques. CONCLUSIONS: Early mobilization following femoral neck fractures has been shown to decrease mortality and morbidity. There is little existing literature on the use of tissue-sparing surgical techniques for this application, and none details the use of the SuperPath technique for it. The described case reports suggest the technique is a viable option for bipolar hemiarthroplasty to treat femoral neck fractures. Appropriately designed future studies are needed to confirm findings and definitively compare outcomes to traditional approaches.