The Risk Assessment and Prediction Tool Accurately Predicts Discharge Destination After Revision Hip and Knee Arthroplasty

BackgroundThe Risk Assessment and Prediction Tool (RAPT) was developed and validated to predict discharge disposition after primary total hip and knee arthroplasty (THA/TKA). To date, there are no studies evaluating the applicability and accuracy of RAPT for revision THA/TKA. This study aims to determine the predictive accuracy of the RAPT for revision THA/TKA.MethodsProspectively collected data from a single tertiary academic medical center were retrospectively analyzed for patients undergoing revision THA/TKA between January 2016 and July 2019. RAPT score was used to predict their postoperative discharge destination and its predictive accuracy was calculated. Patient risk (low, intermediate, and high) for postoperative inpatient rehabilitation facilities or skilled nursing facilities were determined based on the predictive accuracy of each RAPT score. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores.ResultsA total of 716 consecutive revision THA/TKA episodes were analyzed. Overall, predictive accuracy of RAPT for discharge disposition was 83%. RAPT scores <3 and >8 were deemed high and low risk of discharge to a post–acute care facility, respectively. RAPT scores of 4 to 7 were still accurate 65%-71% of the time and were deemed to be intermediate-risk. RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.ConclusionThe RAPT has high predictive accuracy for discharge planning in revision THA/TKA patients. Patient-expected discharge destination is a powerful modulator of the RAPT score and we suggest that it be taken into consideration for preoperative discharge planning.     

Development and Validation of a Model for Predicting Rehabilitation Care Location Among Patients Discharged Home After Total Knee Arthroplasty

BackgroundDemand for joint replacement is increasing, with many patients receiving postsurgical physical therapy (PT) in non-inpatient settings. Clinicians need a reliable tool to guide decisions about the appropriate PT setting for patients discharged home after surgery. We developed and validated a model to predict PT location for patients in our health system discharged home after total knee arthroplasty.MethodsWe analyzed data for patients who completed a preoperative total knee risk assessment in 2017 (model development cohort) or during the first 6 months of 2018 (model validation cohort). The initial total knee risk assessment, to guide rehabilitation disposition, included 28 variables in mobility, social, and environment domains, and on patient demographics and comorbidities. Multivariable logistic regression was used to identify factors that best predict discharge to home health service (HHS) vs home with outpatient PT. Model performance was assessed by standard criteria.ResultsThe development cohort included 259 patients (19%) discharged to HHS and 1129 patients (81%) discharged to home with outpatient PT. The validation cohort included 609 patients, with 91 (15%) discharged to HHS. The final model included age, gender, motivation for outpatient PT, and reliable transportation. Patients without motivation for outpatient PT had the highest probability of discharge to HHS, followed by those without reliable transportation. Model performance was excellent in the development and validation cohort, with c-statistics of 0.91 and 0.86, respectively.ConclusionWe developed and validated a predictive model for total knee arthroplasty PT discharge location. This model includes 4 variables with accurate prediction to guide patient-clinician preoperative decision making.     

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BackgroundTo determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.MethodsRetrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.ResultsThe cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).ConclusionThe LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient’s first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.Level of EvidenceLevel 3-retrospective cohort study.     

Arthroplasty Care Redesign Impacts the Predictive Accuracy of the Risk Assessment and Prediction Tool

BackgroundThe Risk Assessment and Prediction Tool (RAPT) is used to predict patient discharge disposition after total joint arthroplasty. Following a comprehensive, multidisciplinary redesign, our institution noticed a trend toward home discharge in patients with RAPT scores that historically predicted discharge to acute care facilities, presenting an opportunity to redefine the predictive ranges for RAPT.MethodsRetrospectively collected data were analyzed from a single institution in patients undergoing elective primary total joint arthroplasty from January 2016 to April 2017. Predictive accuracy (PA) was calculated for each RAPT score (1-12), RAPT score risk ranges (low, intermediate, and high), as well as overall. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores as related to discharge disposition and the PA of RAPT.ResultsOverall PA of RAPT was 88% (n = 1024 patients). Patients were high risk for acute care facility with a RAPT score of 1 to 3 (PA ≥ 83%), intermediate risk 4 to 7 (PA, 52%-79%), and low risk 8 to 12 (PA ≥ 89%). In multivariable analysis, RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.ConclusionOur multidisciplinary redesign has impacted the PA of RAPT. The original predictive ranges should be modified to reflect the increasing proportion of patients being discharged home following elective arthroplasty procedures. We have identified patient-expected discharge destination as a powerful modulator of the RAPT score and suggest that it be taken into consideration for discharge planning.     

Effect of Posthospital Syndrome on Discharge Disposition and Healthcare Utilization After Primary Total Joint Arthroplasty

BackgroundThe aim of this study is to evaluate the impact of posthospital syndrome (PHS), a physiologically deconditioned state experienced by patients after hospitalizations, on postoperative healthcare utilization and discharge disposition following total hip (THA) and knee (TKA) arthroplasty.MethodsInsurance claims from the Truven MarketScan Databases were used to perform this cross-sectional study of patients who underwent unilateral, primary THA or TKA between January 2010 and December 2016. PHS, defined as a hospitalization within 90 days before surgery, and non-PHS cohorts were compared. Multivariable logistic regression analyses were used to identify risk of postoperative discharge to an extended care facility (ECF), hospital readmissions, and emergency department visits within 90 days.ResultsThis study included 115,465 THA and 190,398 TKA patients who underwent elective surgery for osteoarthritis. PHS was identified in 1.9% and 1.6% of cohorts, respectively, and was more common in patients with higher comorbidities. The PHS cohort had higher crude rates of discharge to ECF (THA 38.8% and TKA 33.8%) and readmissions (21.8% and 18%). Adjusted odds ratios showed that PHS increased risk of disposition to ECF (THA 1.9 and TKA 1.4), readmission (2.8 and 2.0), and emergency department encounters (1.6 and 1.4). Among PHS patients, acute hospitalizations within 30 days of surgery and those lasting greater than 5 days had the highest risk of postoperative healthcare utilization.ConclusionIn this study of commercially insured patients, those with an acute hospitalization within 90 days before elective total joint arthroplasty were nearly twice as likely to be discharged to an ECF and twice as likely to be readmitted in the global postoperative period.     

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.     

Innovative Devices Did Not Provide Superior Total Knee Arthroplasty Outcomes in Post-Operative Rehabilitation: Results From a Four-Arm Randomized Clinical Trial

BackgroundOrthopedic surgeons face an increasing array of post-TKA (total knee arthroplasty) rehabilitation interventions that entail innovative equipment and devices, but their relative effectiveness remains unknown. The study compared patient outcomes among primary unilateral TKA patients participating in one of 4 post-TKA rehabilitation interventions—a standard-of-care intervention and 3 more recently developed physical therapy interventions.MethodsThe Knee Arthroplasty Rehabilitation Outcomes Study is a 4-arm randomized clinical trial conducted across 15 outpatient rehabilitation clinics. The trial evaluated 4 alternative interventions: (1) a stationary recumbent bike (control intervention); (2) a body weight-adjustable treadmill; (3) a recumbent bike and use of a patterned electrical neuromuscular stimulation device; and (4) a body weight-adjustable treadmill and a patterned electrical neuromuscular stimulation device. The study’s outcome measures were patient walking speed and the Knee injury and Osteoarthritis Outcome Score (KOOS) measured at therapy discharge and at follow-up.ResultsThe study enrolled 363 TKA patients with 90-92 patients in each of the 4 study arms. Participants were similar across the 4 groups: They were about 63 years old, 61% female, 67% white, living at home, overweight (mean body mass index = 31.6), with mostly private insurance (61%) or Medicare (32%). Walking speed was similar at admission and discharge; KOOS scores were similar at admission, discharge, and follow-up across the 4 intervention groups.ConclusionThe study found no statistical or clinically meaningful differences across the 4 study arms in walking speed or KOOS outcomes. Clinicians, payers, and policy makers will want to encourage providers and patients to use the least expensive intervention since each provide similar outcomes.Trial RegistrationNCT02426190; https://clinicaltrials.gov/ct2/show/NCT02426190?term=NCT02426190&cntry=US&rank=1.     

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BackgroundFalls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA.MethodsWe queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05.ResultsPatients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts.ConclusionFalls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation.Level of EvidenceIII.     

Who Goes to Inpatient Rehabilitation or Skilled Nursing Facilities Unexpectedly Following Total Knee Arthroplasty?

Background

Inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) represent a significant portion of post-operative expenses of bundled payments for total knee arthroplasty (TKA). Although many surgeons no longer routinely send patients to IRFs or SNFs, some patients are unable to be discharged directly home. This study identified patient factors for discharge to post-acute care facilities with an institutional protocol of discharging TKA patients home.

Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty

BackgroundAs ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence.MethodsPatients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression.ResultsThe most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD.ConclusionsThe most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.     

The Need for an Interpreter Increases Length of Stay and Influences Postoperative Disposition Following Primary Total Joint Arthroplasty

BackgroundMany US patients who undergo total joint arthroplasty have low English proficiency, yet no study has investigated how the need for a translator impacts postoperative outcomes for these patients. We hypothesized that need for an interpreter after total joint arthroplasty would impact discharge disposition and length of stay.MethodsWe performed a retrospective chart review of patients at a single large urban academic institution undergoing single primary total joint replacement from July 2016 to November 2019. Patients were classified as primarily English speaking (E), non-English primary language and did not require an interpreter (NE-N), or non-English primary language and did require an interpreter (NE-I). Data on patient characteristics, length of stay, and discharge disposition were collected.ResultsTotal hip arthroplasty (THA) patients in the NE-I group had significantly longer length of stay than both the NE-N group (2.85 vs 2.28 days, P = .015) and the E group (2.85 s vs 1.87 days, P < .0001). THA patients who required a translator were also significantly less likely to be discharged to home than those who were primarily English speaking (71.4% vs 88.8%, P < .0001). Total knee arthroplasty (TKA) patients in the NE-I group had significantly longer length of stay than the E group (2.66 vs 2.50 days, P = .009). The TKA patients in the NE-I group were significantly less likely to be discharged home than in the E group (74.5% vs 82.4%, P < .0001).ConclusionAlthough interpreter services are provided by the hospital for NE-I patients, the communication barrier that exists affects both length of stay and discharge disposition for both THA and TKA.     

Interval Between Staged Bilateral Total Knee Arthroplasties Does Not Affect Early Medical or Surgical Complications

BackgroundThe purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications.MethodsA retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome.ResultsThe mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration.ConclusionThe interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery.     

Which Socioeconomic Factors Affect Outcomes Following Total Hip and Knee Arthroplasty?

BackgroundStudies have shown that lower socioeconomic status may result in adverse outcomes following total hip (THA) and total knee arthroplasty (TKA). The optimal method of defining socioeconomic status, however, continues to be debated. The purpose of this study is to determine which socioeconomic variables are associated with poor outcomes following THA and TKA.MethodsWe reviewed a consecutive series of 2770 primary THA and TKA patients from 2015 to 2018. Utilizing census data based upon the patient’s ZIP code, we extracted poverty, unemployment, high school graduation, and vehicle possession rates. We collected demographics, comorbidities, discharge disposition, 90-day readmissions, and postoperative functional outcome scores for each patient. We then performed a multivariate regression analysis to identify the effect of each socioeconomic variable on postoperative outcomes.ResultsPatients from areas with high unemployment (P = .008) and low high school graduation rates (P = .019) had a higher age-adjusted Charlson Comorbidity Index. High poverty levels, high unemployment, lower high school graduation rate, and lower vehicle possession rates did not have a significant effect on functional outcomes (all P > .05). In the multivariate analysis, no socioeconomic variable demonstrated an increased rate of rehabilitation discharge, revision, or readmission (all P > .05).ConclusionPatients undergoing THA and TKA from areas with high unemployment and lower educational levels do have more medical comorbidities. However, none of the 4 socioeconomic variables studied are independently associated with higher rates of readmission, discharge to rehabilitation, or worse functional outcomes. Patients from disadvantaged areas should not be denied access to arthroplasty care based on socioeconomic status alone.     

Enhanced Selection of Candidates for Same-Day and Outpatient Total Knee Arthroplasty

BackgroundMedicare removed total knee arthroplasty (TKA) from its inpatient-only list and private insurers created ambulatory surgical codes; these changes bring about logistical challenges for TKA episode planning. We identified preoperatively determined factors associated with hospital length of stay for (1) same-day discharge (SDD) and (2) inpatient TKA defined by Medicare’s 2-midnight rule benchmark.MethodsWe retrospectively reviewed 325 consecutive unilateral primary TKAs performed on patients completing the Perioperative Surgical Home preoperative optimization pathway within a single hospital system. Stepwise logistic regression modeling was performed to identify preoperatively determined factors associated with (1) SDD and (2) inpatient TKA. We compared these models’ ability to discern the length of stay category to the Risk Assessment and Prediction Tool (RAPT) score alone.ResultsThe cohort included 32 (10%) SDD, 189 (58%) next-day discharges, and 104 (32%) inpatients. Lower body mass index (BMI; odds ratio [OR], 0.92; 95% CI, 0.85-0.1.0; P = .04) and fewer self-reported allergies (OR, 0.66; 95% CI, 0.46-0.95; P = .03) were associated with SDD. The SDD model outperformed the RAPT alone (C-statistic, 0.73 vs 0.52; P < .01). Older age (OR, 0.96; P = .04), higher BMI (OR, 0.93; P 0.01), lower RAPT score (OR, 1.2; P = .04), and later surgery start time (OR, 0.80; P < .01) were associated with inpatient discharge. The inpatient model outperformed the RAPT alone (C-statistic, 0.74 vs 0.62; P < .01).ConclusionWe identified preoperatively determined factors associated with (1) SDD as BMI and allergies and (2) inpatient TKA as age, BMI, RAPT score, and surgery start time. Hospitals, providers, patients, families, and payers can use this information for TKA episode planning.     

African American Patients Have Improved Functional Gains and Comparable Clinical Outcomes to Caucasian Patients After Total Hip and Knee Arthroplasty

BackgroundWith the increasing popularity of alternative payment models, minorities who use more postacute care resources may face difficulties with access to quality total hip arthroplasty (THA) and total knee arthroplasty (TKA) care. The purpose of this study is to compare differences in perioperative complications and functional outcomes between African American and Caucasian patients undergoing THA and TKA.MethodsWe reviewed a consecutive series of all primary THA and TKA patients at our institution from 2015 to 2018. Demographics, comorbidities, 90-day complications, readmissions, Veterans Rand 12-Item Health Survey (VR-12), Hip disability Osteoarthritis Outcome Score (HOOS), and Knee injury and Osteoarthritis Outcome Scores (KOOS) were compared between African American and Caucasian patients. A multivariate analysis was performed to control for confounding variables.ResultsOf the 5284 patients included in the study, 1041 were African American (24.5%). Although African American patients had lower preoperative HOOS/KOOS (33.5 vs 45.1, P < .001) and mental VR-12 scores (37.8 vs 51.5, P < .001) compared with Caucasian patients, there was no clinical difference at 1 year in HOOS/KOOS (50.2 vs 50.4), mental VR-12 (55.0 vs 52.6), or physical VR-12 scores (39.5 vs 39.8). When controlling for demographics and medical comorbidities, African American race was associated with increased rehabilitation facility discharge (odds ratio, 1.69; P < .001) but no difference in readmissions or complications.ConclusionAlthough African American patients had lower preoperative functional scores, they made improved postoperative gains when compared with Caucasian patients. Although there was no difference in postoperative complications, further studies should assess social causes for the increase in rehabilitation utilization rates in minority patients.     

Patterns of Weight Change and Their Effects on Clinical Outcomes Following Total Knee Arthroplasty in an Asian Population

BackgroundThis prospective cohort study was designed to evaluate weight change patterns and their effects on clinical outcomes following total knee arthroplasty (TKA) in the Asian population. We hypothesized that Asian patients will have a different pattern of weight change following TKA compared to Western patients and that weight loss following TKA will be associated with better clinical outcomes.MethodsA cohort of consecutive patients who underwent TKA from 2004 to 2015 was included. All patients received a conventional posterior-stabilized TKA implant and underwent a standard perioperative care pathway. Assessments were done preoperatively, at 6 months, and 2 years after surgery. The range of motion, Knee Society Score, Oxford Knee Score, and the Short-Form 36 questionnaire were used to assess outcomes. Height and weight of patients were recorded for body mass index (BMI) calculation. Patterns of weight loss following TKA in this cohort were charted. Clinical outcomes were then analyzed against the change in BMI.ResultsA total of 602 patients (602 knees) were reviewed. Mean age was 66.39 ± 7.27 years. Mean BMI was 27.75 ± 4.51 kg/m². Overall, 63.12% of all our patients gained weight following TKA. Moreover, weight loss did not influence patients’ odds for better clinical outcomes. Furthermore, patients who were in the preoperative BMI category of obese class I were more likely to gain weight as compared to those in the normal category (odds ratio 0.35, 95% confidence interval 0.2-0.61, P < .001). Moreover, older people were more likely to gain more weight compared to younger people. We also showed that the mean 2-year Knee Society Knee Score was significantly higher in the patients who gained weight while the patients who lost weight had the highest mean 2-year Oxford Knee Score and the lowest mean 2-year Knee Society Function Score.ConclusionAsians tend to gain weight following TKA. However, this weight change following TKA does not affect clinical outcomes, which remain good across all BMI groups.Level of EvidenceTherapeutic Level III.     

Disease Progression After Unicompartmental Arthroplasty: Add a Compartment or Revise to Total Knee Arthroplasty?

BackgroundFive percent to 7% of unicompartmental knee arthroplasties (UKA) require revision for disease progression in untreated compartment(s), most commonly to total knee arthroplasty (TKA). TKA requires removal of bone and usually the anterior cruciate ligament. Preserving the UKA and converting to a bicompartmental arthroplasty (BCA) by performing a second UKA is an alternative.MethodsThe results of 73 UKA-BCA patients were compared to 75 patients treated by UKA-TKA revision. Knee Society, Knee Osteoarthritis Outcome Score Joint Replacement, and patient satisfaction scores were collected by a blinded therapist. Patients were asked about their implant preference and recovery. Twenty-two UKA-BCA revision patients had a UKA (6) or TKA (16) in the contralateral knee; thus, a direct comparison of UKA-BCA to both UKA and TKA was possible.ResultsOf the UKA-BCA patients, 69 (94%) had excellent or good, 2 (3%) fair, and 2 (3%) poor outcomes with 1 patient requiring revision to TKA. Of patients with a TKA in the contralateral knee, 13 (81%) preferred the UKA-BCA replacement and 3 (19%) preferred the TKA. All patients said the UKA-BCA revision recovery was similar or easier than their initial UKA. Of UKA-TKA revisions, 59 (79%) had excellent or good, 9 (12%) fair, and 7 (9%) poor outcomes. There was 1 wound infection and 1 re-revision in the UKA-BCA group and 1 wound infection and 3 re-revisions in the UKA-TKA group. The Knee Osteoarthritis Outcome Score Joint Replacement and Knee Society Scores were better for UKA-BCA compared to UKA-TKA.ConclusionUKA-BCA is a successful treatment for disease progression following UKA.     

In a Bundled Payment Model,the Costs Associated With Total Joint Replacement in Those Aged Older Than 80 Years Are Significantly Greater

BackgroundThe number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years.MethodsA retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences.ResultsElective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort’s (n = 554) (P < .0001). For nonelective THA cases, the older cohort’s (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001).ConclusionAlthough primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.     

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients

BackgroundThis study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs).MethodsBetween July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index.ResultsBefore surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3).ConclusionImprovement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.