Faculty Bibliography

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:In order to better understand the clinical benefits of total knee arthroplasty (TKA) and improve the interpretability of the Forgotten Joint Score (FJS-12), the establishment of a meaningful change in score is necessary. The purpose of this study is to determine the threshold of the FJS-12 for detecting the patient acceptable symptom state (PASS) following primary TKA. METHODS:percentile of the cumulative percentage curve of patients who had the KOOS, JR score difference larger than the cut-off value. RESULTS:percentile approach was 77.1 (95% CI [73.9, 81.5]). CONCLUSION/CONCLUSIONS:percentile approaches, respectively. These values can be used to assess the successful achievement of a forgotten joint. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients. METHODS:A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients. RESULTS:A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P < 0.001, P < 0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P < 0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P < 0.001). Surgical time (113 versus 96 versus 98 mins; P < 0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P < 0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P < 0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P < 0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P < 0.001 and 73.8 versus 28.4 versus 29.8; P < 0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P < 0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P < 0.001). CONCLUSIONS:Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.

INTRODUCTION/BACKGROUND:Although increased femoral head size reduces the risk of instability in total hip arthroplasty (THA), it may lead to iliopsoas irritation and increased anterior groin pain. The purpose of this study was to compare outcomes between non-modular dual mobility (NDM) implants, small (≤32mm), and large (≥36mm) fixed bearing (FB) constructs. METHODS:A retrospective review of all primary THAs from 2011-2021 was conducted at a single, urban academic institution. Patients were separated into three cohorts: NDM, ≤32mm, and ≥36mm FB implants. Demographics and outcomes such as length of stay (LOS), dislocation, and anterior groin pain were assessed. Patients were deemed as having groin pain if they received an iliopsoas injection or had extended physical therapy ordered beyond 3 months postoperatively. RESULTS:There were 178 NDM implants, 936 ≤32mm FB, and 2,454 ≥36mm FB implants included. LOS significantly differed between the groups (48.4±43.3 vs. 63.2±40.6 vs. 57.2±38.1 hours; p=0.001). Although not statistically significant, the ≥36mm FB cohort had the highest rate of dislocations (0.6% vs. 0.7% vs. 0.9%; p=0.84). While no patients with a NDM implant received an iliopsoas injection, 9 patients (0.9%) with a ≤32mm FB implant and 9 patients (0.4%) with a ≥36mm implant received an injection (p=0.06). However, 18 (10.1%) patients with a NDM implant, 304 (32.5%) patients with a ≤32mm FB implant, and 355 (14.5%) patients with a ≥36mm FB implant received extended physical therapy 3 months after surgery (p<0.001). CONCLUSION/CONCLUSIONS:NDM implants, as well as FB implants with both small and large head sizes are effective at preventing dislocation. NDM implants did not result in an increase in anterior groin pain compared to ≤32mm, and ≥36mm FB constructs.

BACKGROUND:There are a variety of methods available to treat periprosthetic joint infection (PJI), including 2-stage revision with the use of an antibiotic spacer. This study compares the outcomes of real-component (RC) and all-cement (AC) articulating spacers for total hip arthroplasty (THA) PJI treatment. METHODS:This multicenter retrospective study assessed all articulating spacers placed for THA PJI between April 2011 and August 2020. Patients were dichotomized based on spacer type (RC vs AC). RESULTS:One hundred four patients received articulating spacer constructs (RC group = 75, AC group = 29). Leg-length discrepancy was significantly greater in the AC group after the second stage (3.58 vs 12.00 mm, P = .023). There were no significant differences in reoperation rates following first-stage spacer placement (P = .752) and time to reimplantation (P = .127) between the groups. There were no significant differences in reinfection rates (RC group = 10.0%, AC group = 7.1%, P = 1.000) and reoperation rates following second-stage revision THA (RC group = 11.7%, AC group = 10.7%, P = 1.000). Hospital length of stay (in days) had a trend toward being shorter following the first (7.35 vs 11.96, P = .166) and second stage (3.95 vs 5.43, P = .107) for patients in the RC group. Patients in the RC group were more likely to be discharged home following the first (P = .020) and second (P = .039) stages. CONCLUSION/CONCLUSIONS:Given that there were no differences in reinfection and reoperation rates between the 2 spacer constructs, RC articulating spacers may provide a significant benefit for patient comfort during 2-stage exchange treatment of PJI while adding no increase in risk profile.

Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.

BACKGROUND:Mepivacaine is an intermediate acting amide local anesthetic that can be used for neuraxial anesthesia in total joint arthroplasty (TJA) with a shorter duration of action (1.5-2 hours) compared to the more commonly used local anesthetic bupivacaine. The purpose of this study was to perform a systematic review and meta-analysis comparing bupivacaine and mepivacaine spinal anesthesia during elective TJA and the surgical outcomes of the time to full neurologic motor return, pain, mobility, length of stay (LOS), and complications including transient neurologic symptoms and urinary function. METHODS:PubMed, Ovid MEDLINE, and Ovid Embase were screened for "arthroplasty, spinal anesthesia, bupivacaine, and mepivacaine," in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 159 studies were screened and 5 studies were evaluated. Data were compared regarding motor function return, mobility (distance ambulated), pain (visual analog scale [VAS]), LOS, and postoperative complications. RESULTS:Full-text screening yielded 5 studies (3 randomized controlled trials and 2 retrospective cohort studies), with a total of 1,550 patients. Mepivacaine spinals had an earlier return to motor function (154 minutes vs 170 minutes, 95% CI: [-31.6, -0.9], P = .04), shorter LOS (25.95 hours vs 29.96 hours, 95% CI: [-6.8, -1.2], P = .01), and decreased urinary retention (7.15% vs 10.58%, 95% CI: [-6.3%, -0.6%], P = .02) with no differences in pain (VAS 3.57 vs 3.68, 95% CI: [-2.1, 1.9], P = .90) or distance ambulated (94.2 ft vs 89.1 ft, 95% CI: [-15, 25.2], P = .60) compared to bupivacaine spinal anesthesia. CONCLUSIONS:The method of anesthesia administration has been an increasing area of focus for quicker and safer recovery to allow for early ambulation and facility discharge. The rapid recovery facilitated by mepivacaine may further enable outpatient TJA and enhance patient recovery. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Targets of acetabular inclination and anteversion have been suggested based on a patient's spinopelvic mobility. Current methods in total hip arthroplasty (THA) include manual instrumentation, computer-assisted navigation, and robotic-assisted surgery. This study aims to compare the accuracy of these 3 methods in targeting the functional safe zone. METHODS:This is a prospective multicenter study including a series of 251 consecutive primary posterior THA patients from April 2019 to January 2021. Preoperative lateral standing and sitting spinopelvic radiographs were obtained. Each patient was classified using the Hip-Spine Classification. A functional safe zone plan was determined. Surgeons used their preferred method (manual instrumentation, computer-assisted, or robotic-assisted). Postoperative anteversion and inclination was measured and compared to the preoperative plan. Mean differences between preoperative and postoperative values were calculated. Welch's t-test was used to assess significant between-group differences with P < .05 considered significant. RESULTS:Of the 249 patients, there were 63 manual instrumentation, 68 computer-assisted navigation, and 118 robotic-assisted surgery. Robotic-assisted surgery (rTHA) was significantly more accurate in targeting anteversion (1 ± 2) compared to manual instrumentation (mTHA; 7 ± 6, P < .001) and computer-assisted navigation (cTHA; 6 ± 6, P < .001). rTHA was also significantly more accurate in targeting inclination (1 ± 1) compared to mTHA (8 ± 7, P < .001) and cTHA (6 ± 7, P < .001). Although cTHA had greater accuracy in targeting both inclination and anteversion compared to mTHA, these differences were not statistically significant. CONCLUSION/CONCLUSIONS:Robotic-assisted surgery was more accurate than both computer-assisted navigation and manual instrumentation in targeting the functional safe zone in primary THA. Further research is needed to evaluate the effect of improved accuracy on dislocation rates.

AIMS/OBJECTIVE:Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. METHODS:We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. RESULTS:Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). CONCLUSION/CONCLUSIONS: 2022;3(7):543-548.