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Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge versus Non-Same-Day Discharge

Singh, Vivek; Kurapatti, Mark; Anil, Utkarsh; Macaulay, William; Schwarzkopf, Ran; Davidovitch, Roy I
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.
PMID: 35181447
ISSN: 1532-8406
CID: 5163712

Comparison of Operating Room Air Quality in Primary vs. Revision Total Knee Arthroplasty

Sicat, Chelsea Sue; Schwarzkopf, Ran; Slover, James D; Macaulay, William; Rozell, Joshua C
INTRODUCTION/BACKGROUND:Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Particulate matter (PM) up to 2.5 microns can contain microbial species which may increase infection risk. Our study examines differences in air quality and ABP count in primary (pTKA) and revision total knee arthroplasty (rTKA). METHODS:We analyzed primary and revision TKAs in a single operating room at an academic institution from January 2020 to December 2020. Procedures from March 15, 2020-May 4, 2020 were excluded to avoid COVID-related confounding. 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 (EHR) using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-square. RESULTS:A total of 107 TKA cases were included: 79(73.8%) pTKAs and 28(26.2%) rTKAs. Time spent in room was significantly higher for rTKAs (primary: 176+46.7 minutes vs. revision: 220+47.1,p<0.0001). Compared to pTKAs, rTKAs had significant percent increases in ABP rates for particles measuring 0.3um(+70.4%,p<0.001), 0.5um(+97.2%,p<0.0001), 1.0um(+53.2%,p=0.001), 2.5um(+30.3%,p=0.017), and for PM 2.5(+108.3%,p<0.001) and PM5.0(+105.6%,p<0.001). CONCLUSION/CONCLUSIONS:RTKAs had significantly longer time spent in room and significant percent increases in ABP rates for particles measuring 0.3um, 0.5um, and 1.0um compared to pTKAs. Measurements of PM2.5 and PM5.0 (which can contain large numbers of microbes) were also significantly greater in rTKAs. Further research is needed to determine whether the size and quantity of ABPs translates to higher infection rates following rTKA.
PMID: 35202754
ISSN: 1532-8406
CID: 5172342

Does Retention of the Posterior Cruciate Ligament Lead to a More "Forgotten Joint" Following Total Knee Arthroplasty?

Bieganowski, Thomas; Fiedler, Benjamin; Singh, Vivek; Karlin, Elan; Anil, Utkarsh; Rozell, Joshua C; Schwarzkopf, Ran
INTRODUCTION:Posterior cruciate ligament (PCL) retention may impact a patient's awareness of their artificial joint following primary total knee arthroplasty (pTKA) due to increased proprioception and more native knee kinematics. Therefore, the purpose of this study was to investigate whether cruciate-retaining (CR) or posterior-stabilized (PS) implants influence the Forgotten Joint Score (FJS-12) following pTKA. METHODS:We retrospectively reviewed all patients who underwent pTKA with a CR or PS implant at our institute between October 2017 and March 2021. Of the 6,258 patients identified, 5,587 did not have recorded FJS-12 scores at either three months, one year, or two years postoperatively nor a Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) preoperatively, three months, or one year postoperatively, and these were considered lost to follow up. Thus, a total of 671 cases were identified and subsequently stratified into two cohorts based on whether they received a CR (n=236, 35%) or PS (n=435, 65%) implant. Patients who received PS implants were further divided into constrained (CoN) and non-constrained (NCoN) liner cohorts. Multivariable linear regression analysis was used to compare patient-reported outcome (PRO) scores. RESULTS:There were no significant differences in PRO scores between CR and PS implants at any time point. Patients in the CoN (n=74) cohort had significantly higher FJS-12 scores at one year (CoN: 56.31 + 25.34 vs NCoN: 42.24 + 27.00, p=0.001) and two years (CoN: 58.52 + 33.71 vs NCoN: 46.97 + 27.44, p=0.013) postoperatively compared to patients in the NCoN (n=361) cohort. CONCLUSION:Although our analysis demonstrated significant differences in FJS-12 scores at one and two years postoperatively depending upon the liner constraint, there were no significant differences in FJS-12 scores between CR and PS implants. Therefore, while retention of the PCL does not impact patient awareness of their artificial joint, the level of liner constraint may influence outcomes if the PCL is sacrificed.
PMID: 35090179
ISSN: 1090-3941
CID: 5154942

The effects of tourniquet on cement penetration in total knee arthroplasty

Zak, Stephen G; Tang, Alex; Pivec, Robert; Meftah, Morteza; Austin, Matthew S; Schnaser, Erik; Schwarzkopf, Ran
PURPOSE/OBJECTIVE:Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS:A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS:A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION/CONCLUSIONS:Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.
PMID: 35552801
ISSN: 1434-3916
CID: 5214852

Intraoperative technology increases operating room times in primary total knee arthroplasty

Zak, Stephen G; Cieremans, David; Tang, Alex; Schwarzkopf, Ran; Rozell, Joshua C
INTRODUCTION/BACKGROUND:Optimization of patient outcomes and identification of factors to improve the surgical workflow are increasingly important. Operating room time is one modifiable factor that leads to greater hospital efficiency as well as improved outcomes such as shorter length of stay and fewer infections and readmissions. The aim of this study was to identify factors associated with operative time disparities in total knee arthroplasty (TKA). METHODS:A retrospective review of 7659 consecutive primary TKA cases was conducted. Patient demographic data, discrete operating room (OR) times, use of technology (i.e. robotic-assisted surgery, computer navigation), surgeon experience and the level of training of the first assistant were collected. Multivariate regression analysis was used to determine the effect of hospital characteristics on operative times. Operative times of five minutes or greater were considered to be clinically significant. RESULTS:While the use of technology (182.64 ± 39.85 vs 158.70 ± 37.45 min; B = 26.09; p < 0.0001) and greater surgeon experience (162.14 ± 39.87 vs 158.69 ± 33.18 min, B = 3.15, p = 0.002) were found to increase OR times, level of training of the first assist (161.65 vs 156.4 min; Β = - 0.264; p = 0.487) did not. Of the discrete OR times examined, incision time and total time under anesthesia were negatively impacted by the use of technology. CONCLUSION/CONCLUSIONS:Use of technology was the only study variable found to significantly increase OR times. With increased operative times and limited evidence that technology improves long-term patient outcomes, surgeons should carefully consider the benefits and cost of technology in TKA.
PMID: 35551447
ISSN: 1434-3916
CID: 5214752

Preoperative Patient Expectation of Discharge Planning is an Essential Component in Total Knee Arthroplasty

Feng, James E; Anoushiravani, Afshin A; Morton, Jessica S; Petersen, William; Singh, Vivek; Schwarzkopf, Ran; Macaulay, William
PURPOSE/OBJECTIVE:A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS). MATERIAL AND METHODS/METHODS:This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated. RESULTS:In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge. CONCLUSION/CONCLUSIONS:Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.
PMID: 35527265
ISSN: 2234-0726
CID: 5214032

Trends in Revenue, Cost, and Contribution Margin for Total Joint Arthroplasty 2011-2021

Bieganowski, Thomas; Christensen, Thomas H; Bosco, Joseph A; Lajam, Claudette M; Schwarzkopf, Ran; Slover, James D
BACKGROUND:Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA. METHODS:We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models. RESULTS:Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (p=0.013) in total costs. Direct costs of TKA across all insurance providers (p=0.001 and p<0.001) and total hip arthroplasty (THA) for Medicare (p=0.009) and GMM (p=0.001) plans demonstrated significant upward trends. Despite this, 2011 to 2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018 to 2021 financial data demonstrate a significant downward trend in contribution margin across Medicare (p<0.001) and GMM (p<0.001) insurers for both TKA and THA. CONCLUSION/CONCLUSIONS:Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time if further efficiency and cost-saving measures are not developed.
PMID: 35533825
ISSN: 1532-8406
CID: 5214192

Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes

Singh, Vivek; Nduaguba, Afamefuna M; Macaulay, William; Schwarzkopf, Ran; Davidovitch, Roy I
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.
PMID: 34075486
ISSN: 1434-3916
CID: 4891522

Effect of Total Knee Arthroplasty on Coronal Alignment of the Ankle Joint

Shichman, Ittai; Ben-Ari, Erel; Sissman, Ethan; Oakley, Christian; Schwarzkopf, Ran
BACKGROUND:The effect of total knee arthroplasty (TKA) on the ankle joint is not entirely clear. The purpose of this study was to assess postoperative changes in the coronal alignment of the ankle joint in patients undergoing TKA for various degrees of knee deformity. METHODS:This retrospective study included 107 patients who had undergone TKA for primary osteoarthritis. In all cases, preoperative coronal alignment deformity of the knee was corrected in an attempt to restore the native mechanical axis of the knee. Patients were stratified into three groups according to the degree of knee coronal alignment correction achieved intraoperatively: Group 1 (< 10° varus/valgus correction, n=60), Group 2 (≥10° varus correction, n=30), and Group 3 (≥10° valgus correction, n=17). Knee/ankle alignment angles were measured on full-length, standing anteroposterior imaging preoperatively and postoperatively and included: hip-knee-ankle (HKA) angle, tibial plafond inclination (TPI), talar inclination (TI), and tibiotalar tilt (TTT) angle. RESULTS:Significant changes in ankle alignment, specifically with regard to TPI (9.5°±6.9, p<0.01) and TI (8.8° ±8.8, p=0.03) were noted in the ≥10° valgus correction group compared to the other two groups. Regardless of the degree of knee deformity correction, TKA did not lead to significant changes in the TTT angle. CONCLUSION/CONCLUSIONS:A correction of ≥10 degrees in a genu valgum deformity can affect ankle joint alignment, leading to alterations in the tibial plafond (TPI) and the talar inclination (TI). These findings need to be taken into consideration in assessing candidates for TKA as a possible cause of post-operative ankle pain.
PMID: 35093550
ISSN: 1532-8406
CID: 5153282

How does a "Dry Tap" Impact the Accuracy of Preoperative Aspiration Results in Predicting Chronic PJI?

Christensen, Thomas H; Ong, Justin; Lin, Dana; Aggarwal, Vinay K; Schwarzkopf, Ran; Rozell, Joshua C
INTRODUCTION/BACKGROUND:Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is challenging to diagnose. We aimed to evaluate the impact of dry taps requiring saline lavage during preoperative intraarticular hip aspiration on the accuracy of diagnosing PJI before revision surgery. METHODS:A retrospective review was conducted for THA patients with suspected PJI who received an image-guided hip aspiration from May 2016 to February 2020. Musculoskeletal Infection Society (MSIS) diagnostic criteria for PJI were compared between patients who had dry tap (DT) versus successful tap (ST). Sensitivity and specificity of synovial markers were compared between the DT and ST groups. Concordance between preoperative and intraoperative cultures was determined for the two groups. RESULTS:In total, 335 THA patients met inclusion criteria. A greater proportion of patients in the ST group met MSIS criteria preoperatively (30.2%vs.8.3%, p<0.001). Patients in the ST group had higher rates of revision for PJI (28.4%vs.17.5%, p=0.026) and for any indication (48.4%vs.36.7%, p=0.039). MSIS synovial WBC count thresholds were more sensitive in the ST group (90.0%vs.66.7%). There was no difference in culture concordance (67.9%vs.65.9%,p=0.709), though the DT group had a higher rate of negative preoperative cultures followed by positive intraoperative cultures (85.7%vs.41.1%, p=0.047). CONCLUSION/CONCLUSIONS:Our results indicate that approximately one-third of patients have dry hip aspiration, and in these patients cultures are less predictive of intraoperative findings. This suggests that surgeons considering potential PJI after THA should apply extra scrutiny when interpreting negative results in patients who require saline lavage for hip joint aspiration.
PMID: 35114320
ISSN: 1532-8406
CID: 5153802