Patient Perceptions Regarding Outpatient Hip and Knee Arthroplasties

Background There has been increasing interest in outpatient total joint arthroplasty (TJA) in the orthopedic community, but how patients feel about outpatient TJA is unknown. The purpose of this study was to understand patient perspectives on hip and knee replacements performed in an outpatient setting. Methods We surveyed 110 consecutive patients scheduled for primary TJA in an academic suburban arthroplasty practice regarding their knowledge and perceptions of outpatient TJA. Questionnaires were administered during preoperative clinic visits before discussion of surgery location, length of stay, and before preoperative joint replacement education. Results Fifty-seven percent of respondents were female, and 42.7% were aged 65 years or older. Very few patients expected same-day discharge (n = 3) or a one night stay in the hospital (n = 17). Fifty-four percent of patients were expected to stay in the hospital two or more nights. Only 54.5% of patients were aware that outpatient TJA is an option, with 55.3% of men and 31.7% of women reporting that they were comfortable with outpatient TJA (P = .030). In contrast, 61% and 72.8% believed that faster recovery and decreased likelihood of infection are likely advantages of outpatient TJA. Interestingly, 51.9% felt ambulatory surgery centers are as safe as hospitals, and 62.6% believed that home is the best place to recovery from TJA. Conclusion These observations suggest that there is need for patient education regarding outpatient TJA. As outpatient procedures become more common, it is essential that patients understand the ambulatory surgery process, the benefits and risks of same day discharge, and their role in a successful outpatient experience

Tourniquetless Total Knee Arthroplasty With Modern Perioperative Protocols Decreases Pain and Opioid Consumption in Women

Background This study examined whether a modern total knee arthroplasty (TKA) protocol without a tourniquet results in less patient-reported pain and in-hospital opioid consumption compared to TKA with a tourniquet. Methods A retrospective study of 203 primary unilateral cemented TKAs consecutively performed with or without tourniquet was performed. Identical perioperative pain and blood loss protocols were used in all cases. In tourniquetless TKAs, the tourniquet was not inflated at any time, and sterile CO2 gas compression maximized cement interdigitation. Results After exclusions for scientific confounds, 184 TKAs (93 with tourniquet; 91 tourniquetless) were analyzed. Controlling for multiple covariates, females with a tourniquet reported significantly more pain (P = .002) and opioid consumption (P < .001) the first 24 hours after surgery compared to females without a tourniquet. There were no differences in pain (P = .192) or amount of opioids consumed (P = .203) among males with and without a tourniquet. Tourniquet use resulted in a significant reduction in blood loss for both females (P ≤ .040) and males (P ≤ .020), although the total blood savings of approximately 200 mL is of unknown clinical significance. Conclusion Avoiding tourniquet use during TKA for females may be a relatively risk-free adjunct to minimize opioid consumption during hospitalization. Further study is warranted to elucidate the factors accounting for different outcomes in females and males

Leaving Residual Varus Alignment After Total Knee Arthroplasty Does Not Improve Patient Outcomes

Background Recent popularity of kinematic alignment and constitutional varus has caused some surgeons to leave varus limbs in residual varus after total knee arthroplasty (TKA). This study assessed whether if patients left in residual varus have improved outcomes compared with those fully corrected to neutral alignment. Methods A retrospective review of 361 consecutive primary TKAs was performed. Anatomic tibiofemoral alignment was measured and knees were categorized as neutral, varus, or valgus. Modern Knee Society scores and University of California Los Angeles Activity Level scores were collected at minimum 1-year follow-up. Results After exclusions for confounds and loss to follow-up, 262 knees were available for analysis, 67% (176) of which were preoperatively varus. Sixty-six percent of varus knees were corrected to neutral, 25.6% were left in residual varus, and 8.5% were corrected to valgus. Median Knee Society objective scores at latest follow-up were greater in knees corrected to neutral (97), followed by knees corrected to varus (95), and valgus (93; P = .025), but post hoc comparisons between pairs of medians were not significant. There was no difference between groups in any other outcome measure (P ≥ .245) or the amount of improvement from baseline (P ≥ .423). Sixty percent of native varus patients corrected to neutral, 64% of those corrected to varus, and 40% of those corrected to valgus reported that their knee felt normal (P = .193). Conclusion Findings fail to support the notion that leaving varus knees in residual varus will improve outcomes and pain. Caution is advised when leaving limbs in residual varus after TKA

A Dual-Pivot Pattern Simulating Native Knee Kinematics Optimizes Functional Outcomes After Total Knee Arthroplasty

Background Kinematics after total knee arthroplasty (TKA) have been studied for decades; however, few studies have correlated kinematic patterns to patient reported outcomes. The purpose of this study was to determine if a pattern of lateral pivot motion in early flexion and medial pivot motion in high flexion, simulating native knee kinematics, produces superior clinical outcomes. A second study objective was to determine if a specific kinematic pattern throughout the various ranges of flexion produces superior function and patient satisfaction. Methods 120 consecutive TKAs were performed using sensor embedded tibial trials to record intraoperative knee kinematics through the full range of motion. Established criteria were used to identify lateral (L) or medial (M) pivot kinematic patterns based on the center of rotation within three flexion zones -- 0 to 45° (early flexion), 45 to 90° (mid flexion) and 90° to terminal flexion (late flexion). Knee Society Scores, pain scores, and patient satisfaction were analysed in relationship to kinematic patterns. Results Knee Society function scores were significantly higher in TKAs with early lateral pivot/late medial pivot intraoperative kinematics compared to all other kinematic patterns (p = 0.018) at minimum one-year follow-up. There was a greater decrease in the proportion of patients with early lateral/late medial pivot kinematics who reported that their knee never feels normal (p = 0.011). Higher mean function scores at minimum one-year follow-up (p < 0.001) and improvement from preoperative baseline (p = 0.008) were observed in patients with the most ideal “LLM” kinematic pattern (lateral pivot 0 to 45o and 45 to 90o; medial pivot beyond 90o) compared to those with the least ideal “MLL” kinematic pattern. All patients with the optimal “LLM” kinematic pattern compared to none of those with the “MLL” kinematic pattern reported that they were very satisfied with their TKA (p = 0.003). Conclusion Patients who exhibited an early flexion lateral pivot kinematic pattern accompanied by medial pivot motion in later flexion, as measured intraoperatively, reported higher functional outcome scores along with higher overall patient satisfaction. Replicating the dual-pivot kinematic pattern observed in native knees may improve function and satisfaction after TKA. Further study is warranted to explore a correlation with in-vivo kinematic patterns

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

Introduction: Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged two or three days postoperatively (later). Methods: 530 aseptic rTJAs performed at a single tertiary referral center (12/5/2011-12/30/2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, ASA-PS classification, age, and BMI. All patients were optimized using modern perioperative protocols. The rate of 90-day ED visits and hospital admissions was compared between groups. Results: 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. 62% of the sample was female, with an overall average age and BMI of 63±9.9 (range: 18-92) years and 32±6.9 (range: 18-58) kg/m2. There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (p=0.214). 90-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) did not differ (p=0.545) Conclusions: Using modern perioperative protocols and with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may discharge home the same or next day to preserve hospital beds and resources for more critical medically related illness

Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?

Introduction: In recent years, cost containment relative to patent safety and quality of care for total joint arthroplasty (TJA) has been a key focus for the Centers for Medicare and Medicaid Services (CMS) spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions prior to discharge, but the type and quantity of medical interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. Methods: 1,725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures performed, results of interventions, and all-cause readmissions. Recorded interventions included any that varied from the preoperative treatment plan, were beyond standard-of-care, and could not be completed at home. Results: 759 patients were discharged on postoperative day one. 84% (641/759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. 92% (11/12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in/out catheterizations for urinary retention. 90-day all cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. Conclusion: The majority of patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.This research was supported by the Indiana University Health – Indiana School of Medicine Strategic Research Initiative

Do Medial Pivot Kinematics Correlate With Patient-Reported Outcomes After Total Knee Arthroplasty?

Background Many total knee arthroplasty (TKA) implants are designed to facilitate a medial pivot kinematic pattern. The purpose of this study was to determine whether intraoperative medial pivot kinematic patterns are associated with improved patient outcomes. Methods A retrospective review of consecutive primary TKAs was performed. Sensor-embedded tibial trials determined kinematic patterns intraoperatively. The center of rotation (COR) was identified from 0° to 90° and from 0° to terminal flexion, and designated medial-pivot or non-medial pivot based on accepted criteria. Patient-reported outcomes were measured preoperatively and at minimum one-year follow-up. Results The analysis cohort consisted of 141 TKAs. Mean age and median BMI were 63.7 years and 33.8 kg/m2, respectively. Forty-percent of TKAs demonstrated a medial pivot kinematic pattern intraoperatively. A medial pivot pattern was more common with posterior cruciate-retaining (CR) and posterior cruciate-substituting/anterior lipped (CS) implants when compared to posterior stabilized (PS) TKAs (P ≤.0150). Regardless of bearing type, minimum one-year Knee Society scores and UCLA activity level did not significantly differ based on medial vs non-medial pivot patterns (P ≥.292). For patients with posterior cruciate-sacrificing implants, there were trends for greater median improvement in Knee Society objective (46 vs 31.5 points, P =.057) and satisfaction (23 vs 14 points, P =.067) scores in medial pivot knees. Conclusion A medial pivot pattern may not significantly govern clinical success after TKA based on intraoperative kinematics and modern outcome measures. Further research is warranted to determine if a particular kinematic pattern promotes optimal clinical outcomes

Do Antibiotic Intramedullary Dowels Assist in Eradicating Infection in Two-Stage Resection for Septic Total Knee Arthroplasty?

Background Evidence suggests approximately 40% of intramedullary (IM) canals are culture positive at resection for infected knee arthroplasty. While commonly utilized, no clinical data on the efficacy of antibiotic-eluding IM dowels exist. We quantified treatment success with and without the use of antibiotic-eluding IM dowels in two-stage treatment of periprosthetic knee infection using static and articulating antibiotic cement spacers. Methods 109 consecutive patients who underwent two-stage treatment for periprosthetic knee infection were reviewed. Treatment failure, defined as repeat resection before reimplantation or recurrent infection within 6 months of reimplantation, was evaluated based on spacer type and use of IM dowels, accounting for infection type and systemic host and local extremity grade. Results After exclusions for confounds, articulating spacers without IM dowels were used in 49 (57.7%) cases, articulating spacers with IM dowels in 14 cases (16.5%), and static spacers with IM dowels in 22 (25.9%) cases. Treatment success regardless of infection classification was 85.7% for articulating spacers with IM dowels, 89.8% for articulating spacers without IM dowels, and 68.2% for static spacers with IM dowels (P = .074). In chronically infected poor hosts with compromised extremities, treatment success remained highest in patients with articulating spacers with (90.9%) or without (92.9%) IM dowels compared with static spacers with IM dowels (68.4%) (P = .061). Conclusion Findings suggest that the use of IM dowels did not enhance infection eradication above and beyond that observed for articulating spacers alone, including in the worst cases involving chronically infected poor hosts with compromised extremities

Internet Promotion of Direct Anterior Approach Total Hip Arthroplasty by Members of the American Association of Hip and Knee Surgeons

Introduction The Direct Anterior approach (DAA) in total hip arthroplasty (THA) is of significant interest to both patients and surgeons, largely due to intense marketing. This study addressed the question, ‘What is the level of promotion of DAA THA on the internet by American Association of Hip and Knee Surgeons (AAHKS) members?’ Methods An internet search was performed to identify surgeon-specific websites for each member of the AAHKS using the members’ full name and a previously published set of criteria. Each website was evaluated utilizing a questionnaire to systematically identify claims made regarding proposed DAA specific risks, benefits, as well as the presence/absence of supporting data. Results We identified 1,855 qualified websites. The DAA was referenced on 22.8% (423/1,855) of these websites. Claims regarding DAA specific benefits included; less invasive/muscle sparing (46.3%), quicker recovery (45.2%), decreased pain (28.1%), decreased hospital stay (22.0%), and decreased dislocation risk (16.3%). Potential DAA risks including lateral femoral cutaneous nerve injury, peri-prosthetic/greater trochanteric fracture, and wound complication/hematoma were addressed on only 4.7%, 3.1%, and 1.7% of websites, respectively. Supporting peer-reviewed literature was identified on only 3.6% of DAA websites. Conclusions Over one fifth of AAHKS members promoted the DAA on the internet. Member websites claimed DAA benefits such as faster recovery and decreased pain approximately nine times more frequently than any potential risk of the procedure (p < 0.001). While AAHKS policy does not regulate member marketing, it is the responsibility of all orthopaedic surgeons to disseminate accurate, validated information concerning the procedures we perform

Pain, Narcotic Use, and Functional Outcomes in Revision TKA with & without Adductor Canal Block

Presented as a poster at Indiana Society of Anesthesiologists Annual Meeting 2021