Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.
Background Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach. Questions/purposes We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA? Methods Between
Patients are discharged to home or inpatient settings following primary unilateral total knee arthroplasty (TKA). We identified predictors of inpatient discharge and 3-month postoperative range of motion (ROM) and patient-reported physical function improvement (VR12 PCS) between these discharge settings. We studied prospectively collected cohortdata for 738 TKAs between April 2011 and April 2013. Significant adjusted predictors of inpatient discharge included older age, female gender, surgeon, comorbidity, lower PCS, and BMI >40. Only lower preoperative ROM predicted postoperative ROM. Inpatient discharge and higher preoperative PCS predicted lower PCS improvement. Home-based rehabilitation was associated with greater 3-month PCS improvement and showed no difference with 3-month ROM. TKA inpatient discharge should be based on patient care requirements rather than perceived benefit of improved ROM and physical function.
Background Radiographic outcomes after total hip arthroplasty (THA) have been linked to clinical outcomes. The direct-anterior approach (DAA) for THA has been criticized by some for providing limited exposure and compromised implant position, but allows for routine use of intra-operative fluoroscopy. We sought to determine whether radiographic measurements differed by THA approach using prospective cohorts. Methods Two reviewers blinded to surgical approach examined 194 radiographs, obtained 4–6 weeks after primary THA, and obtained measurements for acetabular inclination angle, acetabular anteversion, radiographic limb length discrepancy (LLD), and femoral offset. All surgeries were performed at a tertiary academic medical center in rural New England by an experienced fellowship-trained arthroplasty surgeon. Measurements for inclination angle, anteversion, LLD, and offset were made into binary yes/no responses based on whether the mean measurement (between the two reviewers) was acceptable or not based on established criteria. Multivariate logistic regression analyses were performed using pre-operative and intra-operative characteristics to identify predictors of acceptability for each measurement. Results The DAA group had higher rates of acceptable acetabular angle (96 vs. 85%, P=0.005), and was protective against an unacceptable angle in an adjusted predictive model (OR 0.16, P=0.005). There were no significant differences between approaches for acceptable anteversion, LLD, or offset. Body mass index of 30–34 was associated with higher odds of unacceptable inclination angle compared to the non-obese group (aOR 6.82, P=0.013). Conclusion DAA for THA was associated with lower odds of unacceptable inclination angle compared to the posterior approach, with no differences in anteversion, LLD, or offset.
BACKGROUND Hospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). The purpose of this study was to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA. METHODS Prospective data were reviewed from 716 consecutive, primary TKA procedures performed by 2 arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans Rand-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to patient demographics and surgical details. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively. RESULTS After adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI <25) overweight (25–29.9) was associated longer LOS by 0.32 days (P=0.038), class-I obesity (30–34.9) by 0.33 days (P=0.024), class-II obesity (35–39.9) by 0.67 days (P=0.012) and class-III obesity (>40) by 1.15 days (P<0.001). Class-III obesity also was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20–29 was associated with a LOS increase of 0.40 days (P=0.014) and PCS<20 with a LOS increase of 0.64 days (P=0.031). CONCLUSION Patient BMI has a dose-response effect in increasing LOS. Poor PCS was associated with increased LOS in a similar dose-response manner. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA.
Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety.Level of Evidence Level III, therapeutic study.
Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: 2017;99-B:531-7.
Background We sought to determine whether several pre-operative socioeconomic status (SES) variables meaningfully improve predictive models for primary total knee arthroplasty (TKA) length of stay (LOS), facility discharge, and clinically significant Veterans RAND-12 Physical Component Score (PCS) improvement. Methods We prospectively collected clinical data on 2,198 TKAs at a high-volume rural tertiary academic hospital from April 2011 through March 2016. SES variables included race/ethnicity, living alone, education, employment, and household income, along with numerous adjusting variables. We determined individual SES predictors and whether the inclusion of all SES variables contributed to each 10-fold cross-validated area under the model’s area under the receiver operating characteristic (AUC). We also used 1000-fold bootstrapping methods to determine whether the SES and non-SES models were statistically different from each other. Results At least 1 SES predicted each outcome. Ethnic minority patients and those with incomes<$35,000 predicted longer LOS. Ethnic minority patients, the unemployed, and those living alone predicted facility discharge. Unemployed patients were less likely to achieve PCS improvement. Without the 5 SES variables, the AUC values of the LOS, discharge, and PCS models were 0.74 (95% CI 0.72–0.77, “acceptable”; 0.86 (CI 0.84–0.87, “excellent”); and 0.80 (CI 0.78–0.82, “excellent”), respectively. Including the 5 SES variables, the ten-fold cross-validated and bootstrapped AUC values were 0.76 (CI 0.74–0.79); 0.87 (CI 0.85–0.88); and 0.81 (0.79–0.83), respectively. Conclusions We developed validated predictive models for outcomes after TKA. Although inclusion of multiple SES variables provided statistical predictive value in our models, the amount of improvement may not be clinically meaningful.
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