Faculty Bibliography

BACKGROUND:Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Our study examines the role of OR size on air quality and ABP count in primary total hip arthroplasty (THA). METHODS:at a single academic institution from April 2019 to June 2020. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-squared test. RESULTS:A total of 116 primary THA cases were included: 18 (15.5%) in the "small" OR and 98 (84.5%) in the "large" OR. Between-group comparisons revealed significant differences in temperature (small OR: 20.3 ± 1.23 C versus large OR: 19.1 ± 0.85 C, P < .0001) and relative humidity (small OR: 41.1 ± 7.24 versus large OR: 46.9 ± 7.56, P < .001). Significant percent decreases in ABP rates for particles measuring 2.5 um (-125.0%, P = .0032), 5.0 um (-245.0%, P = .00078), and 10.0 um (-413.9%, P = .0021) were found in the large OR. Average time spent in the OR was significantly longer in the large OR (174 ± 33 minutes) compared to the small OR (151 ± 14 minutes) (P = .00083). CONCLUSION/CONCLUSIONS:Temperature and humidity differences and significantly lower ABP counts were found in the large compared to the small OR despite longer average time spent in the large OR, suggesting the filtration system encounters less particle burden in larger rooms. Further research is needed to determine the impact this may have on infection rates.

INTRODUCTION/BACKGROUND:Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only (IPO) list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty (TJA) surgery. METHODS:We reviewed all patients who underwent TKA or THA after these procedures were removed from the IPO list. Patients were stratified into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-square tests. RESULTS:Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (p<0.001), though there was no significant difference between cohorts for TKA (p=0.501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (p<0.001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (p<0.001). CONCLUSION/CONCLUSIONS:Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at risk of losing access to care.

INTRODUCTION/BACKGROUND:Patient-reported outcome measures (PROMs) can be used to evaluate post-operative health care quality and patient satisfaction. The Patient's Joint Perception (PJP) question gathers a single PRO to measure how patients appraise their joint. This study compares PJP to the Forgotten Joint Score (FJS) at 21-months post-operation to assess its value. METHODS:A retrospective review was performed at an orthopedic specialty hospital for patients who completed both PJP and FJS questionnaires in 2020-2021 and underwent either a unilateral elective primary Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA). Spearman's correlation coefficients and p-values were calculated to determine external validity of PJP. Floor and ceiling effects were analyzed and considered significant if ≥15% of patients achieved the worst or best score (0-4 for PJP and 0-100 for FJS). RESULTS:In total, 534 patients (327 THA and 207 TKA) were surveyed at 21 months post-operation. External validity against FJS was assessed for both TKA (r=0.66, p<0.01) and THA (r=0.69, p<0.01). For TKA, the floor and ceiling effects were 0.97% and 25.12% for PJP and 3.86% and 4.83% for FJS, respectively. For THA, the floor and ceiling effects were 0.92% and 50.46% for PJP and 2.47% and 20.50% for FJS, respectively. CONCLUSION/CONCLUSIONS:PJP was correlated with FJS moderately for both TKA and THA and can be collected with less burden. However, ceiling effects were significantly higher in both TKA and THA for PJP compared with FJS. Further studies are needed to investigate the questionnaires at additional timepoints and to evaluate the implications of high ceiling effects.

INTRODUCTION/UNASSIGNED:The use of thin highly cross-linked polyethylene (HXLPE) liners in total hip arthroplasty (THA) allows utilisation of larger femoral heads. However, concern surrounding postoperative complications remains. This study aims to investigate rates of revision and re-admission associated with thin HXLPE liners at short-term follow-up. METHODS/UNASSIGNED: = 2027) received >5.1-mm liners with >52-mm size cups. Outcomes were compared using multi-variable logistic regressions while controlling for all significant demographic differences. RESULTS/UNASSIGNED: = 0.068). Liners were exchanged for liner wear in 1 hip (1%), aseptic reasons in 38 hips (66%), and peri-prosthetic joint infection in 19 hips (33%). CONCLUSIONS/UNASSIGNED:Patients undergoing THA with a thin liner were not significantly predisposed to higher rates of revision surgery or poorer clinical outcomes at short-term follow-up when compared to those who received a thicker liner. Consequently, further long-term studies regarding the utility of thin HXLPE implants in reducing complications should be pursued.

BACKGROUND:Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIM/OBJECTIVE:To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA. METHODS:We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients' preoperative status using hierarchical Poisson and linear regressions, respectively. RESULTS:= 0.160) which correlates with a VAS pain score of 3.15. CONCLUSION/CONCLUSIONS:All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

INTRODUCTION/BACKGROUND:Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged the day of surgery. This study compares outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD. METHODS:We retrospectively reviewed all patients who were SDD following TJA from 2015-2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups. RESULTS:Of the 1,778 patients included, 1,384(78%) completed the SDD TJA program and 394(22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. Surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39vs.87.29 minutes; p<0.001). Discharge disposition(p=0.999), 90-day ED-visit (p=0.476), 90-day all-cause readmissions(p=0.999), 90-day all-cause revisions(p=0.563), as well as HOOS,JR and KOOS,JR scores at all time-points did not significantly differ. CONCLUSION/CONCLUSIONS:Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients that are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and experience with value-based care.

Background:Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants. Methods:We retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions. Results:Of the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups. Conclusion:.

INTRODUCTION/BACKGROUND:Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty (THA and TKA) cases to determine the rate and reasons associated with 90-day ED presentations. METHODS:We retrospectively reviewed all patients who underwent primary THA and TKA between 2011-2021. The patients were separated into two cohorts: 1.)SDD;2.)required a longer length-of-stay(LOS). The primary outcome was an ED visit within 90-days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the two groups while accounting for significant demographic variables. RESULTS:Of the 24,933 patients included, 1,725(7%) were SDD and 23,208(93%) required a longer LOS. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6%vs.4.0%,p=0.004). However, when stratified based on the reason for ED visit, no single cause was significant between the two cohorts. The most commonly reported reasons were pain (32.1%vs.26.7%,p=0.064) and other non-orthopedic related medical issues (25.0%vs.29.5%,p=0.206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0%vs.23.4%,p=0.131). CONCLUSION/CONCLUSIONS:Patients that underwent SDD were less likely to present to the ED within 90-days following their surgery compared to non-SDD. Approximately three-fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.

INTRODUCTION/BACKGROUND:As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay. MATERIALS AND METHODS/METHODS:We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences. RESULTS:A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts. CONCLUSION/CONCLUSIONS:Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Preoperative anemia (POA) is a significant predictor for adverse outcomes in primary total hip arthroplasty (THA). Current literature has studied POA stratified by severity. This study aims to find a threshold preoperative hemoglobin (Hb) value for increased risk of adverse outcomes in THA. METHODS:This was a retrospective analysis of primary THA patients with preoperative Hb values from 2014-2021 from an academic orthopedic specialty hospital. Demographics, surgical data, and post-operative outcomes were collected. Patients without preoperative Hb values within the electronic health record (EHR) system or values acquired >30 days preoperatively were excluded. Patients were grouped based on POA severity using WHO criteria. Secondary analysis using discrete preoperative Hb values was performed. P-values were calculated using ANOVA/Kruskal-Wallis and chi-square/Fisher's exact testing with p<0.05 considered significant. RESULTS:A total of 1,347 patients were included, 771(57.2%) patients with POA and 576(42.8%) with normal pre-operative Hb. In the POA group, 292(37.9%) were mild, 445(57.7%) moderate, and 34(4.4%) severe. Increased length of stay (LOS) was seen in moderate (3.9+4.3vs.2.4+2.1,p<0.001) and severe (5.0+3.4vs.2.4+2.1,p<0.0001) groups compared to control. The severe group had higher 90-day readmission and revision rates compared to control. Analysis by discrete Hb values showed increased LOS in Hb values <11g/dL and a greater proportion of patients with Hb values <12g/dL were discharged to skilled nursing facilities. CONCLUSION/CONCLUSIONS:Patients with preoperative Hb <12g/dL should be assessed for other risk factors that may predispose them to post-operative complications. Further investigation is warranted to develop more robust perioperative management strategies for POA patients undergoing THA.