Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundRecent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.ResultsTwenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.ConclusionED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.     

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study

BackgroundMany studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis.MethodsThis is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed.ResultsMean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group.ConclusionCementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.     

How Does Preoperative Central Sensitization Affect Quality of Life Following Total Knee Arthroplasty?

BackgroundCentral sensitization (CS) has been recently identified as a significant risk factor for persistent pain and patient dissatisfaction following total knee arthroplasty (TKA). However, it remains unclear as to whether the preoperative CS persists after the elimination of a nociceptive pain source by TKA, or how CS affects the quality of life after TKA.MethodsA total of 222 consecutive patients undergoing primary TKA were enrolled in the study. All patients were preoperatively screened for CS using the Central Sensitization Inventory (CSI) and categorized into either a CS (n = 55; CSI ≥ 40) or non-CS group (n = 167; CSI < 40). CSI, pain visual analog scale (VAS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score, and satisfaction were recorded at postoperative 2 years.ResultsTwo years after TKA, preoperative CS remained unchanged; there was no difference between preoperative and postoperative CSI scores, and both preoperative and postoperative CSI severity levels were similar (P > .1). The CS group showed worse pain VAS, KSS, and Western Ontario and McMaster Universities Osteoarthritis Index scores than did the non-CS group (P < .01) and more patients in the CS group were dissatisfied with all activities (P < .01). However, a similar percentage of the CS group achieved the previously documented minimal clinically important difference in pain VAS and KSS, compared with the non-CS group. Multivariate regression analysis revealed that preoperative CSI scores were associated with dissatisfaction at postoperative 2 years.ConclusionPreoperative CS was persistent at 2 years after TKA. Although CS patients achieved comparable clinical improvement following TKA, CS patients had worse quality of life, functional disability, and dissatisfaction than non-CS patients.     

The Short Form KOOS,JR Is Valid for Revision Knee Arthroplasty

BackgroundThe Knee Injury Osteoarthritis Outcome Survey, Joint Replacement (KOOS, JR) is a reliable, responsive, and validated patient-reported outcome measure (PROM) of knee health in patients with knee osteoarthritis undergoing unilateral primary total knee arthroplasty (TKA). The validity of the KOOS, JR for revision TKA remains unknown.MethodsWe identified 314 patients who underwent revision TKA and had completed preoperative and 2-year postoperative PROMs. Validation included assessment of local dependence, unidimensionality, internal consistency, external construct validity, responsiveness, and floor effects preoperatively and ceiling effects at 2 years postoperatively.ResultsAmong patients undergoing revision TKA, the KOOS, JR demonstrated an absence of residual item correlation, adequate unidimensionality, high internal consistency (Person Separation Index: 0.897), and high external construct validity with existing validated PROMs, including KOOS Pain (Spearman’s correlation coefficient 0.89) and KOOS activities of daily living (0.90) domains. The KOOS, JR was more responsive (standardized response means: 1.14) to revision TKA than other common knee PROMs. Three percent of revision TKA patients were at the floor (lowest score) preoperatively and 9% reached the ceiling (highest possible score) postoperatively.ConclusionsKOOS, JR performs well in revision TKA patients with regard to internal consistency, external validity, responsiveness, and floor and ceiling effects. Our results support extending its use to revision TKA in both clinical and research settings.     

Pain management after total knee arthroplasty: A prospective randomized study

IntroductionTotal knee arthroplasty (TKA) is a common procedure for improving mobility and quality of life in patients with osteoarthritis. Postoperative pain control management after TKA is still a concern as it relates to patients satisfaction and functional recovery.Many anesthetic regimens and techniques have been explored to decrease postoperative pain and enhance the fast recovery after TKA. The aim of this study was to evaluate the best anesthetic treatment in pain control after TKA.Methods51 patients were included in a randomized prospective study and distributed in three groups. The first group (CG) in which no analgesic protocol was implemented (control group). The second group (LIA group) received an intraoperative local infiltration anesthesia (LIA) (60 ml mixture of two ropivacaine 75mg/10 mL + adrenaline 100μg/10 mL + physiological solution). The third group (FNB group) had only a femoral nerve block (FNB). Continuous outcomes including visual analogue scale (VAS) at 5,24,48 h and at 1 week, morphine consumption and range of motion (ROM) at 1,2,7 days.ResultsThere was significant difference between all groups (p < 0,001) in terms of the VAS score: at 5h after surgery (4.55,2.15,1.82); at 24h (4.15,2.65,3.36); at 48h (3.85,2.45,2.73); at 1 week (2.95,1.80, 1.64), respectively for groups CG, LIA, FNB.ROM was better in LIA and FNB groups than CG: at 1 die after surgery (44°,50°,54°); at 3 dies (69°,70°,71°); at 7 dies (91°,98°,98°), respectively for groups CG, LIA, FNB (p < 0,001).DiscussionLIA and FNB groups both showed a significant reduction at VAS score, better range of motion and less morphine consumption than CG (control group). LIA group has obtained a constant pain control in the postoperative days; FNB group had a good pain control in the hours after surgery, with a decrease in efficacy in the following days.ConclusionFurther studies are still needed in order to define LIA as the reference pain management in TKA.     

Radiographic Outcomes in Treatment of Thumb Basal Joint Arthritis: Does Interposition of Acellular Dermal Allograft Prevent Metacarpal Settling?

Background  Osteoarthritis at the thumb carpometacarpal joint can have a profound impact on quality of life. Here, we evaluate radiographic outcomes in patients who have had open complete trapeziectomy, ligament reconstruction with tendon interposition, and acellular dermal matrix (GraftJacket) interposition—Group A, and compare them with those without GraftJacket interposition—Group B. Materials and Methods  Thirty patients who had undergone operative treatment for thumb basal joint arthritis by a single surgeon from 2009 to 2016 were identified, and charts were retrospectively reviewed for demographic data, surgical and radiographic outcomes, and complications. Results  There was no significant difference in pre- and postoperative radial abduction or pre- and postoperative palmar abduction. The difference in intraoperative joint space was significant ( p = 0.006), but the difference in postoperative joint space was not ( p = 0.310). The average amount of metacarpal settling was 6.9 versus 3.7 mm ( p = 0.035) (Groups A and B, respectively). Three patients in Group A developed an inflammatory reaction to the GraftJacket, and one required reoperation for allograft removal. Conclusion  This study suggests that thumb basal joint arthroplasty with GraftJacket interposition does not lead to more favorable radiographic outcomes at long-term follow-up. The increased costs associated with GraftJacket use may not be justified in light of these outcomes.     

The effects of preoperative chronic opioid use in total hip arthroplasty

BackgroundPerioperative opioid use is becoming an increasingly concerning topic in total joint arthroplasty (TJA). The current study aims to add to the paucity of prior studies that have detailed perioperative opioid use patterns and the effects of preoperative chronic opioid use among a cohort of total hip arthroplasty (THA) patients.MethodsA retrospective analysis of 256 consecutive patients who underwent a THA at our institution between February 2016 and June 2016 was performed. Two cohorts were compared: patients deemed 1) preoperative chronic opioid users, and 2) non-chronic users. Variables compared included baseline characteristics, quality metrics, and patients’ opioid use histories 3 months prior to surgery and 6 months following surgery.ResultsOf the 256 patients, 54 (21.1%) patients were identified as preoperative chronic opioid users. Baseline characteristics including age, gender, BMI, and ASA scores were similar between both cohorts. Discharge disposition, value-based purchasing (VBP) costs, length of stay (LOS), emergency room visits, and postoperative office visits were similar between the two cohorts. Readmission rates (30-day, 90-day, and 6-month) were significantly higher (p < 0.05) in the chronic opioid users cohort. By the 6-month postoperative time period, chronic opioid users were consuming approximately 100-times the morphine equivalents than non-chronic users.ConclusionsThe current study demonstrates that a substantial proportion of preoperative chronic opioid users continue to consume large amounts of opioids up to 6-months following THA surgery. Furthermore, preoperative chronic use is significantly associated with poorer quality outcomes, specifically with respect to readmission rates.Level of evidenceLevel II, Prognostic Study.     

全膝关节置换患者术前结果期望及影响因素研究

目的调查全膝关节置换术患者术前结果期望现状,并分析其影响因素。方法采用骨关节炎指数量表及特殊手术医院-全膝关节置换期望调查工具对198例拟行全膝关节置换术的患者进行调查。结果患者术前结果期望平均分为89.17±13.89。回归分析结果显示,患者年龄、居住同伴、术前关节功能活动评分等级是术前结果期望水平的影响因素(均P0.01)。结论全膝关节置换患者术前结果期望处于较高水平。需加强患者术前期望评估及管理,以提高患者满意度、改善医患关系。     

氨甲环酸联合脉络舒通丸在肿瘤型人工膝关节置换术后的应用效果及安全性

目的:评价氨甲环酸联合脉络舒通丸在肿瘤型人工膝关节置换术后的应用效果及安全性。方法:回顾性收集2019 年3 月—12 月天津市天津医院收治的行肿瘤型膝关节置换术的患者114 例,分为氨甲环酸联合脉络舒通丸组(n =42)、单用氨甲环酸组(n =40)及对照组(n =32)。比较三组患者术前及术后第3 天的血红蛋白水平、术中出血量、术后引流量、术后患肢周径变化、手术时间及平均住院时间,术后不良反应及并发症发生率。结果:术后3 d 联合组及单用氨甲环酸组患者的血红蛋白水平均显著高于对照组。三组患者术中失血量及手术时间无显著差异,联合组及单用氨甲环素组患者术后引流量均显著低于对照组。联合组患者患肢周径变化显著低于单用氨甲环素组及对照组,联合组及单用氨甲环素组患者的住院时间显著低于对照组,差异均有统计学意义。三组患者均未出现术后并发症。结论:术后联合应用氨甲环酸及脉络舒通丸能有效减少肿瘤型人工膝关节置换术后失血量,缩短住院时间,促进患肢消肿,同时不增加患者的并发症发生率。