Tuma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Introduction:Obesity is a public health epidemic that is projected to grow in coming years. Observational data on the epidemiologic profile and immediate postoperative outcomes of obesity and morbid obesity after revision total knee arthroplasty (rTKA) are limited.Methods:Discharge data from the National Inpatient Sample was used to identify patients who underwent rTKA from 2006 to 2015. Patients were stratified into morbidly obese, obese, and not obese control cohorts. An analysis was performed to compare etiology of revision, demographic and medical comorbidity profiles, and immediate in-hospital economic and complication outcomes after rTKA.Results:An estimated 605,603 rTKAs were included in this analysis. Morbidly obese and obese patients were at significantly higher risk for any complication than not obese patients. Patients with obesity were associated with an increased risk of postoperative anemia but a lower risk of peripheral vascular disease and gastrointestinal, and hematoma/seroma complications compared with not obese patients. Patients with morbid obesity were associated with an increased risk of any, hematoma/seroma, wound dehiscence, postoperative infection, pulmonary embolism, and postoperative anemia complications and a lower risk of gastrointestinal complications when compared with not obese patients. Morbidly obese patients had a significantly longer length of stay than both obese and not obese patients, while no significant difference in length of stay was observed between obese and not obese patients.Discussion:Morbidly obese patients are at higher odds for worse postoperative medical and economic outcomes compared with those with obesity after rTKA. As the number of patients with obesity and morbid obesity continues to rise, these risk factors should be considered in preoperative discussions and perioperative protocol optimization.

In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC.Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively.The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient’s fall risk and communicating the fall risk to the health-care team.Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.

In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of .$2 billion, which translates to roughly $41,000 per patient per HAC. » In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of .35 kg/m 2 , male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A722).

Background: With the projected increase in the volume of total joint arthroplasty (TJA), minimizing variations in surgery times, hospital length of stay (LOS), discharge dispositions, and inhospital complication rates would help reduce costs and improve the quality of care. As the move toward bundle payment models gains further traction, providers will be reimbursed based on the quality and cost associated with the surgical episode. As such, it remains critical to design and implement high-quality cost-effective perioperative delivery care models. Lean Six Sigma (LSS) methodology has been well described in the healthcare field as a superior strategy in designing processes aimed at reducing waste while minimizing error rates. We present an institutional experience with the design and implementation of a LSS quality improvement process specific to the TJA pathway, with a hypothesis of expected decrease in case cancellation rate, inhospital LOS, 30-day readmissions, and inpatient rehabilitation utilization after program implementation. Methods: In 2017, the Perioperative Institute of Surgical Excellence (PISE) program for lower limb TJA was designed and implemented at our institution over a 4-month duration. The program was designed following LSS principles as a low-cost easily adoptable model with a goal to reduce hospital LOS, case cancellation rate, 30-day readmissions, and inpatient rehabilitation utilization. Results: A total of 328 patients (128 total hip arthroplasty and 200 total knee arthroplasty) were included in PISE compared with a total of 255 patients (106 total hip arthroplasty and 149 total knee arthroplasty) for the preimplementation cohort. After implementation of the model, and compared with a similar 4-month preimplementation duration, the pilot results revealed an increase in monthly case load by 28.6%, decrease in the 30-day readmission rate by 1.16%, inpatient rehabilitation utilization by 60%, a reduction of the average LOS by 0.8 days, and a case cancellations decrease by 51%. Conclusion: The implementation of the pilot protocol for PISE within our institution was successful in decreasing LOS, inpatient rehabilitation utilization, 30-day readmission, and case cancellation. Further assessment is needed to ascertain sustainability of the protocol over a longer duration and generalizability of the results at different institutions and surgeons.

Introduction:The purpose of this study was to assess the impact of underweight status on in-hospital postoperative outcomes and complications after revision total joint arthroplasty (rTJA) of the hip and knee. Methods: Data from the National Inpatient Sample were used to identify all patients undergoing rTJA in the United States between 2006 and 2015. Patients were divided into two groups based on a concomitant diagnosis of underweight body mass index and a control normal weight group. Propensity score analysis was performed to determine whether underweight body mass index was a risk factor for in-hospital postoperative complications and resource utilization. Results: A total of 865,993 rTJAs were analyzed. Within the study cohort, 2,272 patients were classified as underweight, whereas 863,721 were classified as a normal weight control group. Underweight patients had significantly higher rates of several comorbidities compared with the control cohort. Underweight patients had significantly higher rates of any complication (49.98% versus 33.68%, P = 0.0004) than normal weight patients. Underweight patients also had significantly greater length of stay compared with normal weight patients (6.50 versus 4.87 days, P , 0.0001). Conclusion: Underweight patients have notably higher rates of any complication and longer length of stay after rTJA than those who are not underweight. These results have important implications in preoperative patient discussions and perioperative management. Standardized preoperative protocols should be developed and instituted to improve outcomes in this patient cohort.T otal hip arthroplasty (THA) and total knee arthroplasty (TKA) have greatly improved the quality of life among patients with degenerative joint disease. 1,2 Despite the success of primary procedures, revision TKA (rTKA) and THA (rTHA) remain necessary in response to infections,

Introduction: There remain limited data on the effect of obesity on in-hospital outcomes after revision total hip arthroplasty (rTHA). Methods: Discharge data from the National Inpatient Sample were used to identify patients undergoing rTHA from 2006 to 2015. Propensity score analysis was done to analyze the effects of obesity and morbid obesity on in-hospital economic and complication outcomes after rTHA. Results: The estimated 460,297 rTHAs were done during the study period. Obese patients were more likely to suffer from any complication than not obese patients (41.44% versus 39.41%, P = 0.0085), and morbidly obese patients were more likely to suffer from any complication than obese patients (47.22% versus 41.44%, P , 0.0001). Obesity was associated with increased risk of postoperative anemia compared with not obese patients, while morbid obesity was associated with increased risk of postoperative anemia, hematoma/seroma, wound dehiscence, and postoperative infection (P , 0.05). Morbidly obese patients also had a significantly greater average length of stay (6.40 days) than obese (5.23 days) and not obese (5.37 days) patients (P , 0.0001). Discussion: Although both obesity and morbid obesity are associated with higher risk of in-hospital postoperative complications after rTHA, morbid obesity is a larger risk factor and is associated with a longer length of stay.A lthough primary total hip arthroplasty (THA) has a well-reported track record of excellent outcomes, the number of patients requiring revision THA (rTHA) for reasons such as implant failure, metallosis, infection, and instability has steadily increased in recent decades. 1 In 2014, a total of 50,220 rTHAs were done, and the incidence of the procedure is

Tranexamic acid (TXA) is a commonly used drug that has many uses within multiple medical fields. Within orthopedics, TXA has been used heavily because of the benefits it confers for reducing perioperative bleeding and preventing reductions in hemoglobin/ hematocrit. However, despite these advantages, no set indications for the use of TXA have been defined. The authors performed a literature review assessing current literature for TXA use in knee arthroscopy, shoulder arthroscopy, and hip arthroscopy. Articles were searched in Google Scholar using a combination of keywords including, "tranexamic acid," "arthroscopy," "arthroplasty," "hip," "knee," and "shoulder." The authors reviewed 17 articles that were current and relevant to the use of TXA in arthroscopic procedures based on a focus-grouped discussion. The use of TXA for arthroscopic procedures is growing in both clinical orthopaedic practice and the literature. Although numerous benefits have been noted in knee arthroscopy and shoulder arthroscopy, a paucity of literature on TXA effects in hip arthroscopy still exists, and the topic warrants exploration.