Journal of Arthroplasty最新文献

Background: Predicting postoperative delirium (POD) in patients who have hip fractures is challenging due to its complex mechanism. Therefore, there is a critical need to explore and evaluate a novel predictive indicator.

Methods: There were four hematological markers independently associated with POD that were utilized to construct and evaluate a more reliable predictive indicator for POD. The study employed random sampling, dividing the data into training and validation cohorts in a 7:3 ratio. The strength of association between each predictive indicator and POD was assessed using multivariable logistic analysis and propensity score matching analysis (PSM). Predictive indicators with significant correlations underwent receiver operating characteristic curve (ROC) and characteristic parameter comparisons to identify the optimal predictive indicator. Subsequent validation included the assessment of discriminative ability, correlation, and predictive performance. Furthermore, subgroup analysis was conducted to explore potential interactions.

Results: A total of 1,807 patients were included in this study, with a POD incidence rate of 16.5%. Multivariable logistic analysis and PSM analysis demonstrated that the glucose-to-albumin ratio (GAR) was independently positively associated with POD. Specifically, for every 0.1-unit increase in preoperative GAR levels in hip fracture patients, the risk of POD increased by 1.6 times. The ROC curve indicated that the optimal cut-off value for the GAR was 0.2, with an area under the curve (AUC) of 0.8, sensitivity of 81.2%, and specificity of 59.0%.

Conclusions: Preoperative GAR has a certain predictive value for the occurrence of POD and can function as a novel indicator for predicting POD in geriatric hip fracture patients.

Introduction: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are being increasingly performed as an outpatient procedure. Performing these procedures at an ambulatory surgical center (ASC) has been proposed as a way to create greater access to surgical care, improve efficiency and contain costs. The purpose of this review was to analyze the introduction of a same-day THA and TKA program at Canada's first academic ASC.

Methods: An inpatient THA and TKA cohort and ASC cohort were developed with aggregate data collected from the Canadian Institute for Healthcare Information (CIHI) and Canadian Joint Replacement Registry spanning January 2019 to March 2021. Quality was assessed via patient length of stay, 30-day readmissions, emergency department visits, and revision surgeries. Costs were assessed utilizing methodology and data provided by CIHI. Statistical analysis was performed comparing patient cohorts via χ² and t-tests.

Results: Patients in the ASC cohort were significantly younger, more medically complex and less likely to visit the emergency department within 30 days of surgery (P ≤ 0.001). Overall 3.7% of patients failed same-day discharge and required a short stay. There were substantial cost savings of 1,721 CAD per total joint arthroplasty (TJA) in cases performed at the ASC (P ≤ 0.001).

Conclusion: A THA and TKA performed at an academic-based ASC reduced costs and additional healthcare utilization within 30 days of surgery. This model of same-day surgery at an ambulatory center could help improve timely access to care for a proportion of Canadian patients.

Introduction: Periprosthetic joint infection (PJI) is a severe complication following total joint arthroplasty (TJA). This study aimed to investigate the dynamics of synovial fluid markers following single-stage exchange arthroplasty or debridement combined with antibiotics and implant retention (DAIR) with topical antibiotic infusion for PJI.

Methods: This retrospective study analyzed patient records at a tertiary hospital from March 1, 2018, to May 1, 2023. Patients who received single-stage exchange arthroplasty or DAIR followed by intra-articular antibiotic infusion for PJI were included. Basic demographic details, comorbidities, Charlson Comorbidity Index (CCI) scores, microorganism profile, presence of sinus tract, and antibiotic treatment type were collected. Synovial fluid samples were collected preoperatively and postoperatively every two days for 14 days to quantify synovial white blood cell (WBC) count and polymorphonuclear cell percentage (PMN%).

Results: The study included 140 patients who had a mean age of 63 years and a mean body mass index (BMI) of 25. The results showed a steady decrease in synovial WBC count from preoperative levels to Day 14 postoperative. Patients who had successful outcomes had significantly higher preoperative WBC counts compared to those who had a treatment failure. The synovial PMN% initially increased postoperatively, peaking at days one to two, and then gradually declined. Patients who had successful outcomes showed a faster decline in PMN% compared to those who had persistent infections. Different bacteria exhibited varying preoperative synovial WBC counts and PMN%, but these differences were not statistically significant.

Conclusion: Monitoring synovial WBC count and PMN% can help distinguish between normal postoperative inflammation and persistent infection. Higher preoperative synovial WBC counts are associated with successful outcomes, suggesting their potential role in predicting treatment success. Future research with larger sample sizes is necessary to further validate these findings and improve the management and diagnosis of PJI.

Background: Patient-reported outcome measures (PROMs) are important markers of post-surgical outcomes following total joint arthroplasty (TJA). Recent policies by the Centers for Medicare & Medicaid Services (CMS) will require hospitals to achieve at least 50% postoperative PROM collection rates in order to qualify for their full annual payment in fiscal year 2028. This study aimed to: 1) quantify provider PROMs collection rates for TJA patients; 2) compare mean improvements in postoperative PROMs in TJA patients; 3) identify the proportion of TJA patients achieving substantial clinical benefit (SCB); and 4) identify factors associated with TJA patient completion of matched PROMs and achievement of SCB at one year.

Methods: This retrospective cohort study included 1,493 primary total hip arthroplasty (THA) and 2,959 primary total knee arthroplasty (TKA) patients who underwent surgery at a single institution from May 2019 to December 2023. The primary outcomes were 1-year paired hip or knee PROM collection, measured by the Knee Injury and Osteoarthritis Outcome Score (KOOS JR) and Hip Disability and Osteoarthritis Outcome Score (HOOS JR) surveys, and SCB achievement rates (22 for HOOS JR and 20 for KOOS JR). Secondary outcomes involved identifying factors associated with PROM completion and SCB achievement. Statistical analyses included descriptive statistics, t-tests, and logistic regression analysis.

Results: There were 61.2% of THA patients and 61.1% of TKA patients who completed 1-year paired PROMs, with 72.8% of THA and 53.3% of TKA patients achieving SCB. Factors associated with higher PROMs completion included technology use (PROMs application, text reminders). For TJA patients, a lower preoperative PROM was associated with achievement of SCB at one year. For THA patients, lower BMI was associated with SCB attainment. For TKA patients, men were significantly associated with SCB attainment.

Conclusion: The study indicates compliance with the 50% PROM collection requirement, but this required significant allocation of resources, including the use of a digital care platform. Substantial clinical benefit (SCB) was achieved in 72.8% of THA patients but only 53.3% of TKA patients at one year, and this was associated with certain patient demographic factors. Achieving compliance with the CMS requirement may be difficult for many providers and institutions.

Introduction: There has been a tremendous increase in same-day discharge (SDD) following primary total joint arthroplasty (TJA). While the concept of failure to launch (FTL) has been recently investigated in hospital settings, there is a paucity of data in the ambulatory surgical center (ASC) context. This study aimed to examine the incidence and underlying causes of FTL within an ASC at a major academic medical center.

Methods: A retrospective review from 2021 to 2024 was performed on all patients who underwent same-day surgery at our ASC after intentional selection and medical optimization per institutional protocols. The demographic information, incidence and source of FTL, 90-day readmissions, and reoperations/revisions were recorded. There were 1,974 patients who underwent primary TJA at the ASC during the study.

Results: There were nine patients who required direct hospital admission from the ASC (0.45%). This patient population had a significantly increased American Society of Anesthesiologists (ASA) score compared to patients who were discharged home. Additionally, these patients had a significantly higher number of 90-day emergency department visits. Syncopal episodes were the most common reason for hospital admission from the ASC (66.7%), followed by nausea, seizures, and pain (all 11.1%). After review by attending orthopaedic surgeons and anesthesiologists, only two patients had potentially preventable medical causes for admission.

Discussion: Approximately 99.55% of patients had successful SDD at our ASC, underscoring the importance of proper preoperative screening. Only 0.45% of patients required hospital admission, primarily attributed to hypotension and syncopal events. Interestingly, only two patients in our cohort experienced a potentially preventable instance of FTL. It is crucial that additional efforts be aimed at identifying patients at risk and implementing treatment strategies to prevent postoperative hypotension and syncopal events that may further improve SDD and outcomes in outpatient TJA in the ASC setting.

Background: Recent changes in Medicare reimbursement policies have facilitated the shift of primary total joint arthroplasty (TJA) volume to ambulatory surgical centers (ASC). The ASCs potentially provide a more cost-effective alternative to a hospital-setting TJA. This study investigated Medicare primary TJA utilization and reimbursement trends at ACSs compared to inpatient and outpatient settings between 2019 and 2022.

Methods: Medicare Part A and B claims data from the Centers for Medicare & Medicaid Services (CMS) databases were analyzed. Primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures were identified using Current Procedural Terminology (CPT) codes, Diagnostic Related Group (DRG) codes, and Comprehensive Ambulatory Payment Classification (C-APC) codes based on respective settings. The ASC utilization data was extracted based on year. Billing data for ASCs, hospital outpatient departments (HOPD), and inpatient TJA were compared. Monetary values were adjusted to 2022 dollars using the Consumer Price Index (CPI).

Results: From 2019 to 2022, 1,665,237 primary TJA claims were billed (TKA 1,079,846 claims; THA 585,391 claims), with a 6.1% increase in total utilization. The volume of ASC TJAs increased by 327.1% (TKA 193.8% from 2020 to 2022; THA 61.1% from 2021 to 2022). In the same period, average reimbursement for ASC TJAs rose by 3.9% (TKA 3.4%; THA 1.3%) but showed an 8.1% decline after adjusting for inflation (TKA -8.4%; THA -6.2%). By 2022, ASCs accounted for 8.6% of the total TJAs with the lowest reimbursement per procedure (TKA $8,472.3; THA $8578.7). This shift to ASCs corresponded with $235 million saved compared to inpatient settings and $137 million saved compared to HOPDs per year.

Conclusion: Our study highlights a marked increase in TJA volume at ASCs, with the procedure costing significantly less than HODP or inpatient TJAs. The findings underscore the growing acceptance of these centers as viable, cost-effective alternatives to traditional hospital settings. However, with the declining value of ASC reimbursements, continued monitoring of reimbursement policy is necessary to ensure the sustainability of these cost-effective ASCs for TJAs.

Background: Total knee arthroplasty (TKA) is a crucial orthopaedic procedure used to relieve pain from knee joint degeneration. Concurrently, peripheral artery disease (PAD) presents a major challenge, complicating orthopaedic interventions, particularly TKA, due to its impact on vascular health. Despite advances in surgical techniques and care, patients who have PAD undergoing TKA face heightened risks. Our retrospective study aimed to assess the impact of PAD on TKA outcomes.

Methods: This retrospective cohort study drew data from a healthcare database platform from January 1, 2003, to January 1, 2024. A total of 245,954 patients aged 18 years and older who underwent primary TKA were identified using relevant Current Procedural Terminology (CPT), International Classification of Diseases, 9th Revision (ICD-9), and International Classification of Diseases, 10th Revision (ICD-10) codes. Patients were categorized into two groups: those who had PAD (+PAD) and those who did not have (-PAD). Propensity score matching was performed, resulting in 15,717 patients in each cohort. Rates of postoperative complications were assessed.

Results: Within 30 days post-TKA, patients in the +PAD cohort showed significantly higher risks of complications including acute posthemorrhagic anemia, wound dehiscence, periprosthetic joint infection, lower extremity deep vein thrombosis, pulmonary embolism, pneumonia, acute renal failure, and death compared to patients in the -PAD cohort. Similar trends persisted at the 90-day mark, with an additional increased risk of transfusion requirement, hematoma, myocardial infarction, and periprosthetic fracture in the +PAD cohort. Furthermore, over a 2-year period, the +PAD cohort faced three times the hazards of lower extremity amputation compared to patients in the -PAD cohort.

Conclusion: Given the considerable impact of PAD on TKA outcomes, comprehensive management strategies are crucial to mitigate adverse events, underscoring the need for further research to explore risk stratification and targeted interventions for improved TKA safety in patients who have PAD.

There are many sources of noise production in the operating room, including conversations among the surgical team, background music, electric monitors and alarms, surgical power tools, surgical instrument clattering and hammering, and suction devices. These sources introduce occupational hazards by producing damaging noise levels that exceed noise exposure level guidelines set by the National Institute of Occupational Safety and Health and the Health and Safety Executive. Noise-induced hearing loss affects up to 50% of orthopaedic staff, but few preventative measures are regularly followed in the orthopaedic setting. This review is intended to evaluate existing noise exposure guidelines, present data on sources of noise production in the operating room, and inform and guide orthopaedists toward more effective prevention strategies.

Background: Social determinants strongly influence overall health, including recovery after total joint arthroplasty (TJA). The modern electronic health record (EHR) includes a list of individuals identified by patients as their primary contacts. We aimed to assess whether the relationship between patients and their documented primary contacts was associated with outcomes after TJA.

Methods: We retrospectively reviewed primary, elective total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) at a single institution from June 2011 to December 2022 and stratified patients into two groups: Family (F) [familial relationships to include spouse, first/second degree relative] or Non-Family (NF) [non-familial relationships such as friend, neighbor] based on patient relationship to their primary emergency contact. Baseline characteristics and postoperative outcomes were compared. Binary logistic regression was utilized to assess variables associated with all-cause revision. In total, 17,520 THAs were included: 16,123 (92.0%) in the F group and 1,397 (8.0%) in the NF group. Additionally, 20,397 TKAs were included: 18,819 (92.3%) in the F group and 1,578 (7.7%) in the NF group.

Results: For both THA and TKA patients, having a NF primary contact was independently associated with a higher risk of all-cause revision at the latest follow-up (OR [odds ratio]: 1.48 [95% CI (confidence interval): 1.05 to 2.08], P = 0.025) and (OR: 1.62 [95% CI: 1.10 to 2.38], P = 0.014), respectively. In both THA and TKA, the F group had shorter lengths of stay (P < 0.001) and was more likely to be discharged home (P < 0.001) compared to the NF group.

Conclusion: Total joint arthroplasty patients who have a familial primary contact demonstrate better postoperative outcomes compared to those who do not have a familial contact. Awareness of social support and additional postoperative support for patients who have NF primary contacts may be warranted following TJA.