Validity of vascular trauma codes at major trauma centres

Background

The use of administrative databases in vascular injury research has been increasing, but the validity of the diagnosis codes used in this research is uncertain. We assessed the positive predictive value (PPV) of International Classification of Diseases, tenth revision (ICD-10), vascular injury codes in administrative claims data in Ontario.

Methods

We conducted a retrospective validation study using the Canadian Institute for Health Information Discharge Abstract Database, an administrative database that records all hospital admissions in Canada. We evaluated 380 randomly selected hospital discharge abstracts from the 2 main trauma centres in Toronto, Ont., St. Michael’s Hospital and Sunnybrook Health Sciences Centre, between Apr. 1, 2002, and Mar. 31, 2010. We then compared these records with the corresponding patients’ hospital charts to assess the level of agreement for procedure coding. We calculated the PPV and sensitivity to estimate the validity of vascular injury diagnosis coding.

Results

The overall PPV for vascular injury coding was estimated to be 95% (95% confidence interval [CI] 92.3–96.8). The PPV among code groups for neck, thorax, abdomen, upper extremity and lower extremity injuries ranged from 90.8 (95% CI 82.2–95.5) to 97.4 (95% CI 91.0–99.3), whereas sensitivity ranged from 90% (95% CI 81.5–94.8) to 98.7% (95% CI 92.9–99.8).

Conclusion

Administrative claims hospital discharge data based on ICD-10 diagnosis codes have a high level of validity when identifying cases of vascular injury.

Level of evidence

Observational Study Level III.     

Survival after hepatic resection: impact of surgeon training on long-term outcome

Background

Mortality for liver resection has remarkably improved owing to multiple factors. We sought to determine the impact of the various types of fellowship training on patient survival after liver resection.

Methods

Patients who underwent hepatic resection between 1995 and 2004 in either the Calgary or Capital health regions (Edmonton) of Alberta, Canada, were identified using ICD-9 and -10 codes. Primary outcomes included in-hospital mortality and patient survival according to surgeon volume and training type (surgical oncology v. hepatobiliary v. others).

Results

A total of 1033 patients underwent hepatic resection. Surgeon volume was not predictive of either in-hospital mortality (adjusted odds ratio 0.63, 95% confidence interval [CI] 0.32–1.20) or patient survival (unadjusted hazard ratio 1.11, 95% CI 0.82–1.51). Nonsignificance was also demonstrated for a surgeon’s type of fellowship training.

Conclusion

The various modes of fellowship training do not appear to influence inhospital mortality or patient survival after hepatic resection.     

Intraoperative Synovial C-reactive Protein Is as Useful as Frozen Section to Detect Periprosthetic Hip Infection

Background

Synovial quantification of C-reactive protein (SCRP) has been recently published with high sensitivity and specificity in the diagnosis of periprosthetic joint infection. However, to our knowledge, no studies have compared the use of this test with intraoperative frozen section, which is considered by many to be the best intraoperative test now available.

Questions/purposes

We asked whether intraoperative SCRP could lead to comparable sensitivity, specificity, and predictive values as intraoperative frozen section in revision total hip arthroplasty.

Methods

A prospective study was performed including 76 patients who underwent hip revision for any cause. SCRP quantification (using 9.5 mg/L as denoting infection) and the analysis of frozen section of intraoperative samples (five or more polymorphonuclear leukocytes under high magnification in 10 fields) were performed in all the patients. The definitive diagnosis of an infection was determined according to the Musculoskeletal Infection Society (MSIS). In this group, 30% of the patients were diagnosed with infection using the MSIS criteria (23 of 76 patients).

Results

With the numbers available, there were no differences between SCRP and frozen section in terms of their ability to diagnose infection. The sensitivity of SCRP was 90% (95% confidence interval [CI], 70.8%–98.6%), the specificity was 94% (95% CI, 84.5%–98.7%), the positive predictive value was 87% (95% CI, 66.3%–97%), and the negative predictive value was 96% (95% CI, 87%–99.4%); the sensitivity, specificity, positive predictive value, and negative predictive value were the same using frozen sections to diagnose infection. The positive likelihood ratio was 16.36 (95% CI, 5.4–49.5), indicating a low probability of an individual without the condition having a positive test, and the negative likelihood ratio was 0.10 (95% CI, 0.03–0.36), indicating low probability of an individual without the condition having a negative test.

Conclusions

We found that quantitative SCRP had similar diagnostic value as intraoperative frozen section with comparable sensitivity, specificity, and predictive value in a group of patients undergoing revision total hip arthroplasty. In our institution, SCRP is easier to obtain, less expensive, and less dependent on the technique of obtaining and interpreting a frozen section. If our findings are confirmed by other groups, we suggest that quantitative SCRP be considered as a viable alternative to frozen section.

Level of Evidence

Level I, diagnostic study.     

Medicine versus surgery/anesthesiology intensivists: a retrospective review and comparison of outcomes in a mixed medical–surgical–trauma ICU

Background

With various types of complex patients being treated in a mixed medical–surgical–trauma intensive care unit (ICU), we hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist.

Methods

We reviewed the cases of all patients admitted to a mixed medical–surgical–trauma ICU at a Canadian university teaching hospital in 2007. Patients were assigned to 1 of 2 treatment groups (internal medicine, surgery/anesthesiology) based on the treating intensivist’s training. Our primary outcome was to compare patient mortality in the ICU between the groups. We used generalized estimating equations to determine 10-day mortality after admission to the ICU. A multivariate Cox hazard model was used to determine statistical significance and 95% confidence intervals (CIs) for 11- to 60-day mortality in the ICU.

Results

A total of 961 patients were admitted from January to December, 2007. We found no significant difference between the groups in 10-day mortality (odds ratio 0.73, 95% CI 0.46–1.18, p = 0.20) and 11- to 60-day mortality (hazard ratio 1.43, 95% CI 0.62–3.30, p = 0.40) after admission to the ICU.

Conclusion

In a large university trauma centre that operates a mixed medicine–surgical–trauma ICU, there was no significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology.     

A survey of current practices and preferences for internal fixation of displaced olecranon fractures

Background

Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons’ practices and preferences for internal fixation methods for displaced olecranon fractures.

Methods

Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures.

Results

We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5–37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73–83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5–85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17–3.45) and comminution with a mean impact of 3.34 (95% CI 3.21–3.46) were the 2 factors influencing surgeons’ choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69–80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4–81.7%) and 76.2% (95% CI 70.6–81.0%) for tension band wiring and plating, respectively.

Conclusion

Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures.     

Are Nucleated Cell Counts Useful in the Diagnosis of Infection in Periprosthetic Fracture?

Background

Evaluating for the possibility of prosthetic joint infection in the setting of periprosthetic fracture is important because it determines the course of treatment. However, fracture-related inflammation can make investigations used in the diagnosis of infection less reliable.

Questions/purposes

The purpose of our study was to evaluate synovial fluid nucleated cell counts as a diagnostic test for deep prosthetic infection in patients with periprosthetic fractures around hip and knee arthroplasties. Specifically, we wished to determine the test’s properties (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) using threshold levels of nucleated cell counts as they are otherwise used in the diagnosis of periprosthetic infection.

Methods

Billing codes were used to identify all cases of revision total hip arthroplasty (THA), revision total knee arthroplasty (TKA), open reduction and internal fixation (ORIF) of the femur, and ORIF of the tibia at our institution between 2005 and 2013. A total of 2537 charts were identified and reviewed to reveal 269 patients with 269 periprosthetic fractures about a THA or TKA (10.6% of charts reviewed). Of these, 27 fractures in 27 patients (10% of the periprosthetic fractures identified) underwent aspiration of their total joint arthroplasty to rule out infection before surgical intervention. The decision to aspirate was made by the treating surgeon based on clinical suspicion of infection from the patient history, physical examination, and radiographic findings. Nucleated cell counts from joint aspirates were recorded for all 27 patients. Synovial fluid culture results were then used to calculate the sensitivity, specificity, PPV, and NPV of an elevated nucleated cell count in the diagnosis of infection.

Results

The specificity, sensitivity, PPV, and NPV of an elevated nucleated cell count in the diagnosis of infection were 64% (95% confidence interval [CI, 34.94–75.57]), 100% (95% CI, 19.29–100), 18% (95% CI, 2.37–45.46), and 100% (95% CI, 76.66–100), respectively. Eleven of 27 patients (41%) with joint aspirates had elevated nucleated cell counts. Only two of the 11 patients (18%) with elevated nucleated cell counts had positive synovial fluid cultures. None of the patients with normal nucleated cell counts had positive synovial fluid cultures.

Conclusions

Although quite common, an elevated nucleated cell count has moderate specificity and poor PPV in the diagnosis of infection in the setting of periprosthetic fracture.

Level of Evidence

Level IV, therapeutic study.     

Global Rating Scales and Motion Analysis Are Valid Proficiency Metrics in Virtual and Benchtop Knee Arthroscopy Simulators

Background

Work-hour restrictions and fatigue management strategies in surgical training programs continue to evolve in an effort to improve the learning environment and promote safer patient care. In response, training programs must reevaluate how various teaching modalities such as simulation can augment the development of surgical competence in trainees. For surgical simulators to be most useful, it is important to determine whether surgical proficiency can be reliably differentiated using them. To our knowledge, performance on both virtual and benchtop arthroscopy simulators has not been concurrently assessed in the same subjects.

Questions/purposes

(1) Do global rating scales and procedure time differentiate arthroscopic expertise in virtual and benchtop knee models? (2) Can commercially available built-in motion analysis metrics differentiate arthroscopic expertise? (3) How well are performance measures on virtual and benchtop simulators correlated? (4) Are these metrics sensitive enough to differentiate by year of training?

Methods

A cross-sectional study of 19 subjects (four medical students, 12 residents, and three staff) were recruited and divided into 11 novice arthroscopists (student to Postgraduate Year [PGY] 3) and eight proficient arthroscopists (PGY 4 to staff) who completed a diagnostic arthroscopy and loose-body retrieval in both virtual and benchtop knee models. Global rating scales (GRS), procedure times, and motion analysis metrics were used to evaluate performance.

Results

The proficient group scored higher on virtual (14 ± 6 [95% confidence interval {CI}, 10–18] versus 36 ± 5 [95% CI, 32–40], p < 0.001) and benchtop (16 ± 8 [95% CI, 11–21] versus 36 ± 5 [95% CI, 31–40], p < 0.001) GRS scales. The proficient subjects completed nearly all tasks faster than novice subjects, including the virtual scope (579 ±169 [95% CI, 466–692] versus 358 ± 178 [95% CI, 210–507] seconds, p = 0.02) and benchtop knee scope + probe (480 ± 160 [95% CI, 373–588] versus 277 ± 64 [95% CI, 224–330] seconds, p = 0.002). The built-in motion analysis metrics also distinguished novices from proficient arthroscopists using the self-generated virtual loose body retrieval task scores (4 ± 1 [95% CI, 3–5] versus 6 ± 1 [95% CI, 5–7], p = 0.001). GRS scores between virtual and benchtop models were very strongly correlated (ρ = 0.93, p < 0.001). There was strong correlation between year of training and virtual GRS (ρ = 0.8, p < 0.001) and benchtop GRS (ρ = 0.87, p < 0.001) scores.

Conclusions

To our knowledge, this is the first study to evaluate performance on both virtual and benchtop knee simulators. We have shown that subjective GRS scores and objective motion analysis metrics and procedure time are valid measures to distinguish arthroscopic skill on both virtual and benchtop modalities. Performance on both modalities is well correlated. We believe that training on artificial models allows acquisition of skills in a safe environment. Future work should compare different modalities in the efficiency of skill acquisition, retention, and transferability to the operating room.     

A New and Simple Predictive Formula for Non-Sentinel Lymph Node Metastasis in Breast Cancer Patients with Positive Sentinel Lymph Nodes,and Validation of 3 Different Nomograms in Turkish Breast Cancer Patients

Background

Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement.

Patients and Methods

Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement.

Results

The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64–0.8), 0.665 (95% CI 0.59–0.73), and 0.696 (95% CI 0.59–0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63–0.81).

Conclusion

The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.     

Does arthroscopic subacromial decompression improve quality of life

Introduction

There has been a significant rise in the volume of subacromial decompression surgery performed in the UK. This study aimed to determine whether arthroscopic subacromial decompression improves health related quality of life in a cost effective manner.

Methods

Patients undergoing arthroscopic subacromial decompression surgery for impingement were enrolled between 2012 and 2014. The Oxford shoulder score and the EQ-5D™ instruments were completed prior to and following surgery. A cost–utility analysis was performed.

Results

Eighty-three patients were eligible for the study with a mean follow-up duration of 15 months (range: 4–27 months). The mean Oxford shoulder score improved by 13 points (95% confidence interval [CI]: 11–15 points). The mean health utility gain extrapolated from the EQ-5D™ questionnaire improved by 0.23 (95% CI: 0.16–0.30), translating to a minimum cost per QALY of £5,683.

Conclusions

Subacromial decompression leads to significant improvement in function and quality of life in a cost effective manner. This provides justification for its ongoing practice by appropriately trained shoulder surgeons in correctly selected patients.     

Amputation and the assessment of limb viability: perceptions of two hundred and thirty two orthopaedic trainees

INTRODUCTION

The management of complex extremity injury, which may require assessment of limb viability and performance of amputation, is a challenge to those involved in its emergent and definitive care. Concern exists regarding the exposure of orthopaedic trainees to such cases due both to changes in training and centralisation of trauma services.

SUBJECTS AND METHODS

This is a web-based observational study by survey, investigating the confidence and perceived adequacy of training of UK orthopaedic specialist trainees in the assessment of limb viability and amputation surgery. 222 responses from 888 trainees were required to achieve a < 5% error rate with 90% confidence; 232 surveys were completed.

RESULTS

Trainee confidence in dealing with the assessment of limb viability is high despite infrequent exposure to cases. The majority of trainees perceive their training in limb viability assessment as adequate. For performance of amputation, exposure is minimal, confidence is lower and 36% of trainees regard their training as inadequate.

CONCLUSIONS

Limb viability assessment is an area in which trainees feel confident and well trained. There is, however, a perceived training inadequacy in amputation surgery and a corresponding lack of confidence for many trainees, irrespective of training year. This is the first study to offer an insight into specific training experiences of junior orthopaedic surgeons at a national level and it should drive the development of opportunities for trainees to develop skills in amputation surgery.     

Meta-analysis of retrojugular versus antejugular approach for carotid endarterectomy

Introduction

The retrojugular approach for carotid endarterectomy (CEA) has been reported to have the advantages of shorter operative time and ease of dissection, especially in high carotid lesions. Controversial opinion exists with regard to its safety and benefits over the conventional antejugular approach.

Methods

A systematic review of electronic information sources was conducted to identify studies comparing outcomes of CEA performed with the retrojugular and antejugular approach. Synthesis of summary statistics was undertaken and fixed or random effects models were applied to combine outcome data.

Findings

A total of 6 studies reporting on a total of 740 CEAs (retrojugular approach: 333 patients; antejugular approach: 407 patients) entered our meta-analysis models. The retrojugular approach was found to be associated with a higher incidence of laryngeal nerve damage (odds ratio [OR]: 3.21, 95% confidence interval [CI]: 1.46–7.07). No significant differences in the incidence of hypoglossal or accessory nerve damage were identified between the retrojugular and antejugular approach groups (OR: 1.09 and 11.51, 95% CI: 0.31–3.80 and 0.59–225.43). Cranial nerve damage persisting during the follow-up period was similar between the groups (OR: 2.96, 95% CI: 0.79–11.13). Perioperative stroke and mortality rates did not differ in patients treated with the retrojugular or antejugular approach (OR: 1.26 and 1.28, 95% CI: 0.31–5.21 and 0.25–6.50).

Conclusions

Currently, there is no conclusive evidence to favour one approach over the other. Proof from a well designed randomised trial would help determine the role and benefits of the retrojugular approach in CEA.     

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees'' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE®, Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.     

Risk Calculators Predict Failures of Knee and Hip Arthroplasties: Findings from a Large Health Maintenance Organization

Background

Considering the cost and risk associated with revision Total knee arthroplasty (TKAs) and Total hip arthroplasty (THAs), steps to prevent these operations will help patients and reduce healthcare costs. Revision risk calculators for patients may reduce revision surgery by supporting clinical decision-making at the point of care.

Questions/purposes

We sought to develop a TKA and THA revision risk calculator using data from a large health-maintenance organization’s arthroplasty registry and determine the best set of predictors for the revision risk calculator.

Methods

Revision risk calculators for THAs and TKAs were developed using a patient cohort from a total joint replacement registry and data from a large US integrated healthcare system. The cohort included all patients who had primary procedures performed in our healthcare system between April 2001 and July 2008 and were followed until January 2014 (TKAs, n = 41,750; THAs, n = 22,721), During the study period, 9% of patients (TKA = 3066/34,686; THA=1898/20,285) were lost to followup and 7% died (TKA= 2350/41,750; THA=1419/20,285). The outcome of interest was revision surgery and was defined as replacement of any component for any reason within 5 years postoperatively. Candidate predictors for the revision risk calculator were limited to preoperative patient demographics, comorbidities, and procedure diagnoses. Logistic regression models were used to identify predictors and the Hosmer-Lemeshow goodness-of-fit test and c-statistic were used to choose final models for the revision risk calculator.

Results

The best predictors for the TKA revision risk calculator were age (odds ratio [OR], 0.96; 95% CI, 0.95–0.97; p < 0.001), sex (OR, 0.84; 95% CI, 0.75–0.95; p = 0.004), square-root BMI (OR, 1.05; 95% CI, 0.99–1.11; p = 0.140), diabetes (OR, 1.32; 95% CI, 1.17–1.48; p < 0.001), osteoarthritis (OR, 1.16; 95% CI, 0.84–1.62; p = 0.368), posttraumatic arthritis (OR, 1.66; 95% CI, 1.07–2.56; p = 0.022), and osteonecrosis (OR, 2.54; 95% CI, 1.31–4.92; p = 0.006). The best predictors for the THA revision risk calculator were sex (OR, 1.24; 95% CI, 1.05–1.46; p = 0.010), age (OR, 0.98; 95% CI, 0.98–0.99; p < 0.001), square-root BMI (OR, 1.07; 95% CI, 1.00–1.15; p = 0.066), and osteoarthritis (OR, 0.85; 95% CI, 0.66–1.09; p = 0.190).

Conclusions

Study model parameters can be used to create web-based calculators. Surgeons can enter personalized patient data in the risk calculators for identification of risk of revision which can be used for clinical decision making at the point of care. Future prospective studies will be needed to validate these calculators and to refine them with time.

Level of Evidence

Level III, prognostic study.     

Mesenteric angiography for the localization and treatment of acute lower gastrointestinal bleeding

Background

There is limited evidence regarding the effectiveness and complications of mesenteric angiography in the diagnosis and management of acute lower gastrointestinal bleeding (ALGIB). Our objective was to determine the complications and outcomes of mesenteric angiography in patients with ALGIB and to identify predictors of a positive result at angiography.

Methods

We identified and reviewed the records of all patients who underwent mesenteric angiography for ALGIB at our institution during a 10-year period. We compared potential predictors of positive versus negative angiograms.

Results

Of 47 mesenteric angiograms in 35 patients, 22 (47%, 95% confidence interval [CI] 33%–61%) revealed a source of bleeding, most commonly the colon. Hematomas developed in the groins of 3 patients (6.4%, 95% CI 0%–18%), and 1 of these patients also experienced a myocardial infarction during the procedure. None of the potential predictors were significantly associated with a positive result at angiography, although the confidence intervals were wide. Twenty patients (57%, 95% CI 41%–74%) continued to bleed after the angiogram, and 18 of the patients (51%, 95% CI 35%–68%) were discharged without a definitive diagnosis.

Conclusion

With a diagnostic success of about 50%, mesenteric angiography may play an important part in the diagnosis and management of patients with ALGIB; however, one or more large, prospective multicentre studies are needed to more clearly define its role. Canadian surgeons have the opportunity to initiate collaborative multicentre studies to address such diagnostic and therapeutic clinical questions.     

Not all total joint replacement patients are created equal: preoperative factors and length of stay in hospital

Background

We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity.

Methods

Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category.

Results

The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364–0.631; ≥ 5 d: OR 0.57, 95% CI 0.435–0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274–0.659; ≥ 5 d: OR 0.489, 95% CI 0.314–0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities.

Conclusion

Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.