Aims. To examine incidence of complications associated with outpatient
total hip arthroplasty (THA), and to see if medical comorbidities
are associated with complications or extended length of stay. Patients and Methods. From June 2013 to December 2016, 1279 patients underwent 1472
outpatient THAs at our free-standing
Aims. COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic. Methods. An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers. Results. In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an
The brief answer is no….I do not believe that outpatient total joint arthroplasty is the emergent standard of care. However, for some patients and some surgeons I do believe that outpatient total joint arthroplasty can be performed safely and with greater comfort and convenience for the patient. Further, for the surgeon, it can provide greater control over the care environment if performed at an
Aims. The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an
Problem. Total hip replacement (THA) is among the most common and highest total spend elective operations in the United States. However, up to 7% of patients have 90-day complications after surgery, most frequently joint dislocation that is related to poor acetabular component positioning. These complications lead to patient morbidity and mortality, as well as significant cost to the health system. As such, surgeons and hospitals value navigation technology, but existing solutions including robotics and optical navigation are costly, time-consuming, and complex to learn, resulting in limited uptake globally. Solution. Augmented reality represents a navigation solution that is rapid, accurate, intuitive, easy to learn, and does not require large and costly equipment in the operating room. In addition to providing cutting edge technology to specialty orthopedic centers, augmented reality is a very attractive solution for lower volume and smaller operative settings such as
Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and
Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an
Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an
Acetabular cup positioning remains a real challenge and component malpositioning after total hip arthroplasty (THA) can lead to increased rates of dislocation and wear. It is a common cause for revision THA. A novel 3D imageless mini-optical navigation system was used during THA to provide accurate, intraoperative, real-time, and non-fluoroscopic data including component positioning to the surgeon. This retrospective comparative single surgeon and single approach study examined acetabular component positioning between traditional mini-posterolateral THA and mini-posterolateral THA using the 3D mini-optical navigation system. A retrospective chart review was conducted of 157 consecutive (78 3D mini-optical navigation and 79 traditional non-navigation methods) THAs performed by the senior author using a mini-posterolateral approach at an
Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay. From June 2013 through March 2018, 43 patients (44 hips) underwent conversion (n=9) or revision (n=35) THA at a free-standing
At our tertiary, large, academic healthcare system, we have access to an academic medical center (AMC), a community based, orthopedic friendly, efficient hospital (CBH) and several ambulatory care centers (ASC) which are being prepared to provide same day discharge (SDD) TJA and UKA. We had a near-capacity AMC with an excellent ability to care for medically and technically complicated TJA patients. However, efficiency was less than desired regardless of case complexity with an average effective case time of 4 hours. Concurrently, the orthopaedically, under-utilized community-based hospital (CBH) wanted to increase volume, improve margins, and become a TJA Center of Excellence with the ability to provide an efficient Hospital Outpatient Department (HOPD) and SDD TJA surgery experience. Methods. The CBH had a main operating floor and a separate floor of four OR suites which were repurposed with the goal of utilizing these rooms for TJA four days per week with an average of 3.5 cases per room per day. We preferentially performed primary, uncomplicated TJA, UKA, and minimally invasive TJA at the CBH. Revision surgeries, patients with extensive medical comorbidities, and complex primary surgeries would be performed at the AMC. Our goals were to decrease costs, readmissions, length of stay, and increase margins at the CBH while increasing efficiency, revenue and volume. Protocols were developed to facilitate SDD UKA and THA at both hospitals as well as rapid recovery protocols for TKA at both hospitals with the understanding that the CBH would perform more of these cases but the efficiency could also be implemented at the AMC when possible. We also needed a strategy to deal with TKA and eventually THA being removed from the Inpatient Only (IPO) list. CMS has utilized the “Two-Midnight Rule” to define outpatient status for both THA and TKA. This has distinct financial implications for the facility's reimbursement with outpatient being $10,123 on average versus $12,380 for inpatient status. A protocol-based system was put in place to make both hospitals compliant with the removal of TKA from the IPO List in order to avoid Quality Improvement Organization (QIO) and Recovery Audit Contractor (RAC) after implementation. Results. Comparing FY 2018 to FY 2019, volume increased 26.4% at the CBH. Outpatient case volume rose substantially from 14 cases to 243. Volumes were slightly decreased at the AMC (−4.57%) resulting in a substantial increase in margin contribution for the parent enterprise. Quality metrics at the CBH (surgical site infections (SSI), length of stay (LOS), readmissions, and mortality) were improved. LOS improved from 52% to 71% discharge before 48 hours. The LOS decreased 12% for THA and 8.1% for TKA. CBH readmission rates decreased from 1.38% to 0.9% with no deaths. Surgeon satisfaction is greatly improved as their volume, efficiency, quality metrics, and finances were enhanced. Financial performance was improved in aggregate and per case for the CBH. Although the CBH per-case revenue was 80.3% and 74.4% of the AMC for THA and TKA: the net margins were 3.6% and 18.8% higher for THA and TKA, respectively. The increased efficiency, lower hospital cost and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. Conclusions. A shifting reimbursement landscape, value-based payment initiatives, and increasing volume have challenged traditional TJA delivery systems. This demonstrates one strategy to help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient settings including
Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay. From June 2013 through March 2018, 43 patients (44 hips) underwent conversion (n=12) or revision (n=32) THA at a free-standing
Total knee arthroplasty (TKA) is reliable, durable, and reproducible in relieving pain and improving function in patients with arthritis of the knee joint. Cemented fixation is the gold standard with low rates of loosening and excellent survivorship in several large clinical series and joint registries. While cementless knee designs have been available for the past 3 decades, changing patient demographics (i.e. younger patients), improved implant designs and materials, and a shift towards TKA procedures being performed in
Length of hospital stay has been decreased to the point where the next logical progression in arthroplasty surgery is outpatient arthroplasty procedures. This trend has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, anterior cruciate ligament reconstruction, foot and ankle procedures, and rotator cuff repair. Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation. Today, hip, knee and shoulder arthroplasty can be performed safely as outpatient procedures by implementing surgical and protocol refinements. Understanding and addressing, safely, the reasons that surgeons and patients believe they “need” a hospital admission is the cornerstone to outpatient arthroplasty. This program can be highly beneficial to patients, surgeons, anesthesia,
Introduction. Over the past several decades, numerous surgical procedures have been perfected in the inpatient hospital setting and then evolved into outpatient procedures. This has been shown to be a safe and economical transition for many orthopedic procedures. A prime example is ACL reconstruction. We report here our early experience with our initial consecutive series of outpatient UKA's done in a free standing ASC (ambulatory surgery center). Materials and Methods. From 8/26/2008 to 5/20/12 there were 60 UKA's performed as outpatient procedures at a free standing ASC. Average patient age was 57.7 years (range of 46–69). Medical comorbidities included 22 patients with HTN and 7 with diabetes. All patients had general anesthesia with periarticular injection of the involved knee (25 cc's of Marcaine with epinephrine 1:100,000) and an intraarticular injection after closure of the capsule with 25 cc of Marcaine with epinephrine mixed with 5 cc of morphine sulfate. Patients without allergy to sulfa were given 200mg of Celebrex bid for three days and hydrocodone/acetaminophin 10/325 1–2 tabs q4 hours prn pain. Patients were discharged home when stable, ambulating with aids as needed, with length of stay ranging from 60–180 minutes (average of 85 minutes). Results. No patients required admission to the hospital for any reason. There was one hemarthrosis in a medial UKA which developed on postoperative day 4. There was uneventful resolution of this event with conservative management and an excellent result was achieved. The vast majority of patients were ambulating well and without walking aids at the 2 week postoperative evaluation. The total number of UKAs performed by the author in the ASC since 8/26/2008 is now 282, still without any complications requiring admission to the hospital. Conclusion. Outpatient UKA performed in an
Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital-based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. The purpose of this study is to compare PROM data in patients undergoing outpatient vs. inpatient total knee arthroplasty (TKA) performed in the first year of a newly opened outpatient facility. Methods. An internal quality metric database analysis was performed on patients undergoing TKA between 2/14/14 and 5/1/2015. Outpatient TKA was performed at an
The discussion of outpatient unicompartmental knee arthroplasty (UKA) requires proof that it can be done safely and effectively, and also begs the question of whether it can be performed in an
Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. This is a retrospective comparison of PROM data in patients undergoing outpatient vs. inpatient total hip arthroplasty (THA). Methods. An internal quality metric database analysis was performed on patients undergoing THA between 2/14/14 to 5/1/2015. Outpatients underwent THA at a newly opened
In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations. Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation.Aims
Methods
The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression.Aims
Methods