Relationship between length of stay and dislocation rate after total hip arthroplasty

The purpose of this study was to determine if decreased postoperative inpatient time (length of stay; LOS) after total hip arthroplasty (THA) was correlated with an increase in the dislocation rate after discharge. Reduced access to physical therapy, nursing reinforcement of dislocation precautions, and medical supervision could lead to a higher rate of adverse behaviors (such as inappropriate flexion and rotation) and accidents that might have otherwise been avoided in the initial 3 -months after surgery. We examined records from 850 patients (2 surgeons) who underwent primary THA from 1993 to 1998. LOS had progressively decreased over the 4 years since implementation of a clinical pathway (CP) in late 1993. The average LOS in 1992 was 6.6 days and was lowest in 1998 at 3.9 days. The dislocation rate before the CP was 0.5%. The dislocation rate increased significantly to 3.9% after implementation of the CP (P =.015). Use of the CP offers numerous advantages but is associated with a higher dislocation rate.     

Effect of body mass index on range of motion and manipulation after total knee arthroplasty

This study evaluates the effects of increased body mass index (BMI) on postoperative range of motion (ROM) and rate of manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) in 391 primary TKAs. Range of motion and incidence of MUA were retrospectively collected and compared between 4 BMI groups (I, BMI <25; II, BMI 25-29.9; III, BMI 30-34.9; IV, BMI >35) using χ² or Fisher exact tests. Patients with higher BMIs had a greater incidence of MUA (I, 9.7%; II, 19%; III, 20%; IV, 15%) and lower preoperative and postoperative ROM. Women had lower ROM and a higher rate of MUA. Age was not a significant predictor of ROM or rate of MUA. Patients at greater risk of complications after TKA should be counseled about realistic surgical outcomes.     

Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty

This study aims to identify whether patient-level or provider-level characteristics are most influential on a patient's length of stay in the acute care hospital. A data set containing a nationally representative sample of inpatient discharge abstracts was used. Multilevel linear regression models were used to evaluate the associations between patient-level and provider-level characteristics on patients' lengths of stay. The target population included 322 894 discharges with a primary procedure code for primary total knee arthroplasty and 193 553 discharges for total hip arthroplasty. The variables associated with the greatest increases in length of stay were a higher comorbidity level among patient level attributes (+17.4%) and low surgeon volume among provider-level characteristics (+18.8%). Provider-level characteristics, particularly provider volume, had a greater impact on length of stay.     

The results of knee manipulation for stiffness after total knee arthroplasty with or without an intra-articular steroid injection

Background:

Stiffness after total knee arthroplasty (TKA) requiring manipulation has a reported incidence of 1.3-54%. The purpose of this study was to compare the incidence of stiffness warranting manipulation using two different pain management protocols. We also studied the effect of an intra-articular injection of local anesthetic and steroid given at the time of manipulation on the range-of-motion (ROM) at last follow-up.

Materials and Methods:

A total of 286 TKAs (248 patients between January 2002 and December 2003) were compared to a second group of 292 TKAs (251 patients between January 2004 and March 2006). The first group received patient-controlled analgesia (PCA) for postoperative pain management. The second group had a peri-articular injection of a steroid-containing local anesthetic at the time of surgery, but no postoperative PCA. All patients undergoing manipulation in the second group also received a similar intra-articular injection at the time of manipulation as well. Only patients with minimum 12 months follow-up after manipulation were included in the study.

Results:

The overall incidence of stiffness requiring manipulation in both groups was similar at 2.4% and 2.1%, respectively (P = 0.1). The end results of manipulation with and without injection showed a significantly higher final ROM in patients who had had an injection at the time of manipulation (P = 0.001). The difference was due to the fact that patients who had an injection lost no motion from that achieved at the time of manipulation.

Conclusion:

We were unable to demonstrate a significant reduction in the incidence of stiffness after TKA using a modern pain management protocol. However, injection of a local anesthetic and steroid at the time of manipulation did have a significant influence on preserving the ROM that was obtained at the time of manipulation.     

Continuous passive motion after total knee arthroplasty

Sixty-two patients undergoing primary total knee arthroplasty were studied prospectively. There were 42 patients in whom continuous passive motion (CPM) was used after surgery and 20 controls. The two groups were comparable with respect to age, diagnosis, sex, weight, and preoperative deformity and motion. The mean length of time required for CPM patients to achieve 90 degrees of flexion (9.1 days) was shorter than that for the control group (13.8 days). At the time of discharge from the hospital, however, there was no significant difference between the groups in amount of either flexion or extension. All patients had venograms performed after arthroplasty; the incidence of positive studies indicating thrombophlebitis was 45% in CPM patients and 75% in controls. These data demonstrate that CPM after knee arthroplasty enables patients to recover motion more quickly and affords some protection against deep vein thrombosis.     

Assessing short-term functional outcomes and knee alignment of computer-assisted navigated total knee arthroplasty

This retrospective study examined the relationship between the mechanical axis of the knee throughout its functional arc and functional outcomes in patients with computer-assisted navigation total knee arthroplasty. Data on final intraoperative functional arc alignment were obtained on 76 patients who had computer-assisted navigation total knee arthroplasty over a 2-year period and correlated with scores from postoperative Short Form 12 and Western Ontario and McMaster Universities functional outcome surveys. No correlation was found between functional arc alignment and outcomes from Western Ontario and McMaster Universities or Short Form 12 surveys; however, subgroup analysis of patients with more than 3° average final intraoperative alignment throughout the functional arc of motion demonstrated increased difficulty with daily activities (P = .05). The results indicate that patients with more than 3° average alignment throughout the functional arc of motion perform more poorly with daily activities postoperatively.     

Impact of regional and local anaesthetics on length of stay in knee arthroplasty

Background: Regional and local anaesthetic techniques are thought to improve postoperative pain control and functional outcomes following total knee arthroplasty, potentially leading to a reduction in hospital length of stay. Objectives: The objective of this study was to evaluate the reporting quality and discuss the clinical findings of the available literature on these modalities that included length of stay as a study outcome. Data sources: The electronic databases Pubmed, Scopus, Medline, Web of Science and Cochrane library were searched using key words. Review methods: Eight‐hundred and forty‐three papers were identified in the search. Fifteen of these met the inclusion criteria. Eight further studies were identified from their reference lists to give a final total of 23 studies that were reported against the consolidated standards of reporting trials (CONSORT) 2001 statement checklist. Results: The mean criteria CONSORT score was 17.3/22 (79%). The majority of studies that compared femoral nerve blocks with placebo or conventional pain management modalities failed to demonstrate a significant reduction in length of stay. All studies that compared femoral nerve blocks with epidurals found no significant difference in length of stay. Only half of the studies comparing local anaesthetic techniques to placebo or conventional pain management methods found a significant reduction in length of stay. Conclusions: The reporting quality has specific deficiencies in the areas of sample size calculation, randomization whilst there was under‐reporting of blinding. Regional and local anaesthetic techniques have not demonstrated a clear reduction in hospital length of stay. Epidurals and femoral nerve blocks have similar impacts on length of stay.     

Preoperative knee stiffness and total knee arthroplasty outcomes

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non-stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P < .0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.     

The role of flexion contracture on outcomes in primary total knee arthroplasty

This study examined the role that flexion contracture plays in postoperative outcomes after total knee arthroplasty using a retrospective database review. The relationships between preoperative and postoperative knee extension, walking ability, stair climbing ability, Knee Society scores, pain scores, and knee function scores were studied in 5,622 knees. A preoperative flexion contracture was associated with an increased incidence of a persistent postoperative flexion deformity. A postoperative flexion contracture was associated with poorer postoperative results. Furthermore, a postoperative hyperextension deformity of greater than 10 degrees was associated with an increased risk of suboptimal pain and Knee Society scores. Knee extension deformities play a substantial detrimental role in the functional outcome of primary total knee arthroplasty.     

Recurrent hemarthrosis after total knee arthroplasty

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1–30 months). All seven required open synovectomy an average of 21 months (6–31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19–60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.     

The association between comorbidity and length of hospital stay and costs in total hip arthroplasty patients: a systematic review

We performed a systematic review on the relationship between comorbidity and length of hospital stay (LOS) and hospital costs (HC). Electronic databases were systematically searched for relevant studies, conducting methodological quality assessment and best-evidence synthesis: 317 articles were identified, 10 of which fit the inclusion criteria; nine studies determined the relationship between comorbidity and LOS, with eight reporting a positive correlation; five studies were considered to be of high quality, four of which found a positive correlation; two studies analyzed the relationship between comorbidity and HC and reported significantly higher HC for patients with comorbidities, and were considered to be of high quality. In conclusion, there is limited evidence that patient comorbidity has a positive correlation with LOS and HC.     

Factors affecting range of motion in total knee arthroplasty using high flexion prosthesis: A prospective study

Background:

High flexion implants have been reported to provide better range of motion (ROM). The few studies analyzing the factors affecting the ROM are scarce. This study aims to find the factors that affect ROM when using a high flex knee design (INDUS knee).

Materials and Methods:

Two hundred and fifty three consecutive patients of total knee arthroplasty (TKA) done by using INDUS knee prosthesis between Sept 2008 and Sept 2009 were included in the study. The cases with osteoarthritis (OA) and Rheumatoid arthritis (RA) were included in study. 5 patients were lost to followup and 248 patients (267 knees, 19 bilateral, 221 OA, and 46 RA) were analyzed for the following factors – sex, age, body mass index (BMI), preoperative ROM, flexion deformity, preoperative total knee score and functional score, time of tourniquet release and patella resurfacing. Subgroup classification using above factors was performed and statistical analysis of effect of all the above factors on final knee ROM was done. Assessment was done preoperatively and at 3 months, 6 months and 1 year postoperatively. The final outcome evaluation was done at one year followup.

Results:

The mean age was 68.2 years (range 40-89 years) with 79 males and 189 females. The mean knee range improved from 97.62 ± 11° to 132 ± 8°. Factors that positively affect ROM of INDUS knee prosthesis at the end of 1 year were preoperative ROM, total knee score and functional score, and diagnosis of osteoarthritis, whereas BMI, preoperative flexion deformity has a negative influence on final flexion at the end of 1 year. Age and gender of the patients, patella resurfacing, and use of two different tourniquet protocols did not affect the final outcome.

Conclusion:

Preoperative ROM and preoperative functional status are the most important factors affecting final range. Patients should be counseled accordingly and made to understand these factors.     

Osteolysis after total knee arthroplasty

Osteolysis ranks as the most significant cause of revision surgery in both total hip arthroplasty and total knee arthroplasty (TKA). The factors leading to osteolysis in TKA are unique and sometimes preventable. Changes in polyethylene manufacturing and implant design are striving to improve overall wear. In this review, we discuss osteolysis as it relates to TKAs. The etiology, diagnosis, contributing factors, and management are presented. The final section focuses on future improvements in TKA design, which may ultimately decrease the rate of osteolysis.     

Sagittal plane positioning of the femoral component in total knee arthroplasty

The authors evaluated 623 total knee arthroplasties to determine the relationship between sagittal plane position of the femoral component and the final range of motion of the prosthetic knee. Two different prostheses were evaluated (Posterior Cruciate Condylar and A.G.C.) radiographically and functionally. Variation in sagittal plane position ranged from 20 degrees flexion to 20 degrees extension. No correlation between the sagittal plane position of the femoral component in either prosthesis and the final knee range of motion could be found. Sagittal plane femoral component position in the prostheses studied did not affect final range of motion when component position was between 20 degrees flexion and 20 degrees of extension.     

Effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients

The isolated effect of physical therapy (PT) on total joint arthroplasty hospital length of stay (LOS) has not been studied. A prospective cohort study was conducted on 136 primary total joint arthroplasties (58 hips, 78 knees). The LOS was determined by the operative start time until the time of discharge. On postoperative day (POD) 0, 60 joints remained in bed, 51 moved to a chair, and 25 received PT (22 ambulated, 3 moved to a chair). Length of stay differed for patients receiving PT on POD 0 (2.8 ± 0.8 days) compared with POD 1 (3.7 ± 1.8 days) (P = .02). There was no difference in PT treatment based on nausea/vomiting, pain levels, or discharge location. Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed.     

Total knee arthroplasty: Limb length discrepancy and functional outcome

Background:

Limb length discrepancy and its effects on patient function have been discussed in depth in the literature with respect to hip arthroplasty but there are few studies that have examined the effect on function of limb length discrepency following total knee arthroplasty (TKA). The aim of this study was to determine whether limb length discrepancy after TKA in patients with bilateral osteoarthritis of knee with varus deformity affects functional outcome.

Materials and Methods:

Fifty-four patients with bilateral osteoarthritis of knee with varus deformity, who were operated for total knee arthroplasty from 1996 to 2008, were reviewed retrospectively. The patients were divided into two groups. Thirty patients (mean age 64 years) were operated for unilateral TKA and thirty patients (mean age 65.8 years) were operated for bilateral total knee arthroplasty. Six patients underwent staged surgery and were included in both groups as the time interval between the two surgeries was more than the minimum 6-month follow-up period specified for inclusion in the study. The limb length discrepancy was measured and statistically correlated with the functional component of the Knee Society Score.

Result:

In the unilateral group (n=30), the mean limb length discrepancy was 1.53 cm (range: 0-3 cm) and the mean functional score was 73 (range: 45-100). In the bilateral group (n=30), the mean limb length discrepancy was 0.5 cm (range: 0-2 cm) and the mean functional score was 80.67 (range: 0-100). A statistically significant negative correlation was found between limb length discrepancy and functional score in the unilateral group (Spearman correlation coefficient, r =−0.52, P=0.006), while no statistically significant correlation was found in the bilateral group (Spearman correlation coefficient, r = −0.141, P=0.458).

Conclusion:

Limb length discrepancy affects functional outcome after total knee arthroplasty, especially so in patients of bilateral osteoarthritis with varus deformity undergoing surgery of only one knee.     

Predicting length of stay after shoulder arthroplasty

Background/HypothesisThe annual volume of shoulder arthroplasty (SA) in the United States has increased more than 400% from 1993 to 2008 and is projected to increase an additional 300% from 2008 to 2030. The purpose of this study was to develop and internally validate a preoperative predictive nomogram for length of stay (LOS) after SA. We hypothesized that patient-specific covariates are responsible for increased LOS after SA. If sufficiently accurate, such a nomogram would be valuable for defining which patients would qualify for outpatient SA.MethodsA systematic review of the literature was performed to identify patient variables responsible for increased LOS defined as ≥ 2 days. Patient data were collected from 234 consecutive SA cases performed between 2010 and 2016 at a single tertiary healthcare center by six orthopedic surgeons. The cohort was separated into two groups: short LOS (≤1 day; n = 98) and extended LOS (≥2 days; n = 136). Logistic regression coefficients were used to construct an LOS nomogram that was internally validated by the bootstrapping method. A receiver operating characteristic curve plot determined the discriminative ability of the nomogram. Generalizability was assessed using external validation with a new data set of 193 records prospectively collected from 2016 to 2018.ResultsUnivariate analysis demonstrated that female sex, cancer history, anticoagulation and oral hypoglycemic agents, undergoing humeral head replacement for fracture, and discharge to a facility were significant predictors for an LOS ≥2 days. The following patient covariates were found to be significant in the development of the nomogram: age, female sex, procedure type, disease-modifying antirheumatic drugs (DMARDs), renal dysfunction, and diabetes drugs. The prediction accuracy of this model was good (area under the curve of the receiver operating characteristic curve plot of 0.793). External validation of the model reported an area under the curve of 0.664.ConclusionPatients most suitable for expedited postoperative stay are healthy middle-aged males that are not on diabetic medications or DMARDs, have no renal disease, and undergo resurfacing, total SA, or reverse total SA. This nomogram may be an additional clinical decision-making tool for effectively preparing for postoperative care and decreasing LOS for an episode of care, subsequently reducing the total cost of care. Future work would focus on undertaking a prospective multicenter study involving institutions that perform a high annual volume of SAs.Level of evidenceLevel III; Retrospective Cohort Study     

High-flexion vs conventional prostheses total knee arthroplasty: a meta-analysis

Whether high-flexion prostheses are superior to conventional prostheses after total knee arthroplasty (TKA) remains controversial. Therefore, this meta-analysis was conducted to evaluate the effects of these 2 different designs. After a comprehensive search, 11 trials with 1204 knees were eligible for data extraction and pooled analysis. The results demonstrated that there were no differences in range of motion of high-flexion posterior-stabilized vs standard posterior-stabilized TKA (weighted mean improvement, 0.93°; 95% confidence intervals, −0.75° to 2.60°; P = .28), range of motion of high-flexion cruciate-retaining vs cruciate-retaining TKA (2.06°; 0.06°-4.17°; P = .06), weight-bearing flexion (2.05°; 0.99°-5.08°; P = .19), Knee Society Scores (1.59 points; 0.42-3.60 points; P = .12), and Hospital for Special Surgery Scores (0.84 points; 0.37-2.04 points; P = .17) with at least 1-year follow-up. No infection, loosening, and osteolysis were found. The current evidences cannot confirm that high-flexion prostheses are superior to conventional prostheses.     

Extended length of stay and postoperative complications in octogenarians with hypertension following revision total knee arthroplasty

BackgroundPrior studies have shown hypertensive patients to be at an increased risk of postoperative complications following various surgeries, including revision total knee arthroplasty (rTKA). However, whether these risks are compounded in octogenarian patients has not yet been well explored. The purpose of this study was to analyze whether hypertensive octogenarians, aged 80 to 89, undergoing rTKA are at an increased risk of postoperative complications relative to the younger hypertensive geriatric population aged 65 to 79.MethodsA national database was used to collect data for all hypertensive patients who underwent rTKA from 2006 to 2018. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, medical comorbidities, and postoperative complications were compared between the two cohorts. Bivariate and multivariate analyses were performed.ResultsOf the 6,599 hypertensive patients who underwent rTKA, 5,477 (83.0%) patients were in the aged 65 to 79 group and 1,122 (17.0%) patients were in the aged 80 to 89 group. Following adjustment to control for demographic and comorbidity data, relative to patients in the 65 to 79 age group, hypertensive patients who were 80–89 years old had an increased risk of unplanned reintubation (OR 3.52; p = 0.008), urinary tract infection (OR 2.08; p = 0.011), postoperative transfusion (OR 1.90; p < 0.001), myocardial infarction (OR 2.55; p = 0.017), and extended length of hospital stay (OR 1.77; p < 0.001).ConclusionHypertensive octogenarian patients undergoing rTKA have an increased risk of an extended length of stay and other postoperative complications relative to their younger hypertensive geriatric counterparts. Orthopaedic surgeons should consider a multi-disciplinary approach to managing hypertension in these octogenarian patients prior to surgery to minimize this risk. However, even with this risk, an octogenarian age should not be used independently in evaluating if a hypertensive geriatric patient is a safe rTKA candidate.     

Effectiveness of best practice implementation in reducing hip arthroplasty length of stay

A transfer of a best practice model was performed between a new institution in the United Kingdom and a leading orthopedic hospital in the United States. The quality concepts transferred to the UK were surgical and hospital throughput, hospital facility design, an Interdisciplinary Preoperative Patient Education Program, infection control standards, and a standardized rehabilitation model. The new hospital was officially opened in February 2004, and the average length of stay for total hip arthroplasty between February and December 2004 was 6.1 +/- 3.0 days, a substantial reduction of 5 days on average. The infection rate was reduced from 1% to 0.16%. This study supports the notion that the implementation of a best practice approach significantly reduces length of stay as well as infection rate.