Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Introduction. Inpatient rehabilitation services following joint replacement have been estimated to cost over $3 billion/ yr. A shift in reimbursement strategies to bundle payments with the goal of decreasing cost and improving quality has given discharge disposition after joint replacement a front row seat. Our objectives were (1) to establish a correlation between the accuracy of current tools utilized to predict discharge location and (2) compare preoperative and postoperative patient oriented outcomes (POO's) according to discharge disposition. Methods. 188 consecutive total hip arthroplasty (THA) surgeries performed by a single surgeon were prospectively studied. Pre-intervention assessment of the probable and preferred discharge disposition was performed using one of 5 tools (1) experienced surgical coordinator evaluation (2) Risk Assessment and Prediction Tool (RAPT); (3) Charlson Score; (4) ASA Score; and (5) Patient Self-Reported Health Status. Demographic characteristics, Visual Analogue Scale, QWB-7, SF-36, WOMAC, clinical scores were recorded before and after surgery. Correlation between final discharge disposition (home vs rehab) and its predictors was performed. Preoperative and postoperative outcomes were compared, p<0.05 was considered significant. Results. Most accurate predictor of discharge disposition was determined by our experienced surgical coordinator (OR: 11.05; 95% CI of 2.21 to 55.32; p<0.001), followed by the RAPT (OR: 1.56; 95% CI of 1.29 to 1.90; p=0.01). We found a significant difference in age (Rehab: 72.4 SE 1.2 vs Home: 70.3 SE 1.0; p=0.01) and length of stay (Rehab: 3.6 SE 0.01 vs Home: 3.14 SE 0.07; p<0.001) between those discharged to rehab than those discharged home. Mean follow-up time was 2.22 years (range 1–4 years). There was a significant difference between groups on most outcome measures preoperatively (rehab worse than home; p<0.001). Both groups demonstrated significant improvement in all patient perceived outcome measures after THA, but those discharged to rehab continue to report worse scores for the QWB (Rehab: 0.62 SE 0.02 vs Home: 0.67 SE 0.01; p=0.02) and Hip Harris Score (Rehab: 83.07 SE 1.75 vs Home: 88.65 SE 1.31; p=0.01). Discussion. Clinical intuition and personal interaction proved to be the best predictor for discharge disposition. Worse outcomes were observed in patients being discharged to rehab. For any tables or figures, please contact the authors directly

In-hospital length of stay (LOS) and discharge disposition following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, we wished to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge disposition following robotic-arm assisted (RO THA) versus conventional technique Total Hip Arthroplasty (CO THA). This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge disposition was comparable between the two groups. In the multivariate model, age, need for PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days. Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in discharge destination. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies

Purpose: The current health care climate encourages an early discharge directly home. Efforts to increase efficiency and decrease length of stay require accurate pre-planning of patient discharge following total joint arthroplasty (TJA). The purpose of this study was to develop and evaluate an easily administered form to preoperatively predict patient discharge disposition following TJA. Method: A form was generated by a multidisciplinary group of clinicians which identified a set of preoperative factors relevant to patient discharge including age, gender, body mass index, comorbidities, preoperative ambulatory status, projected postoperative weight bearing, home environment and location, and caregiver assistance. Data were collected from a retrospective review of 516 medical charts for patients that had undergone primary total knee arthroplasty (TKA) (n=103), revision TKA (n=104), bilateral TKA (n=102), primary total hip arthroplasty (THA) (n=106), and revision THA (n=101). A stepwise multinomial logistic regression model was used to identify predictors of discharge to a skilled nursing facility (SNF), rehabilitation facility, or home, using SPSS version 11.5 statistical software (SPSS Inc., Chicago, IL). Results: Patients were more likely to be discharged to either a SNF or rehabilitation facility if they underwent bilateral TKA (p< 0.001); were female (p< 0.001), have their heart disease monitored (p=0.003); or are older (p< 0.001). Patients are more likely to be discharged home if preoperatively they are capable of independent ambulation in the community (p=0.014). Patients discharged to either a SNF or rehabilitation facility were not significantly different except patients undergoing bilateral TKA were more likely to be discharged to a rehabilitation facility (p< 0.001). Conclusion: We identified factors associated with discharge to a SNF, rehabilitation facility, or home following elective joint replacement surgery. With further validation, this model may be a useful tool for preoperatively predicting a patient’s discharge disposition, which is valuable to the hospital, clinicians, patients, and families in efficiently preparing for postoperative care

BACKGROUND. This study aims to identify recent trends in discharge disposition following bilateral total knee arthroplasty (TKA) as well as factors that predispose patients to enter inpatient rehabilitation facilities (IRF) or skilled nursing facilities (SNF) versus home-rehabilitation (HR). The goal was to identify risk factors that predispose prolonged hospital stays and identify changes in management over time that may be responsible for decreased length of stay (LOS) and a HR program. METHODS. A retrospective cohort study design was used to collect and analyze clinical and demographic data for 404 consecutive bilateral primary total knee arthroplasty (TKA) procedures. Patients who underwent elective primary bilateral total knee arthroplasty from 2011 to 2016 were identified from hospital records at a single institution. Clinical and demographic data including sex, age, and disposition were analyzed. RESULTS. 404 bilateral TKAs were performed by 17 surgeons at a single institution from 2011 to 2016. The average age for bilateral TKA was 63y (31.4–86.6) and 59% were females (239/404). From 2011 to 2016, an increase of 61% (10% to 71%) was noted with regards to home discharge (22.035, <0.001), as well as an increase in the ratio of males being discharged home vs IRF/SNF (1.04 vs 2.4; 2.304, 0.008). Univariate analysis for factors associated with home discharge showed significance for age <60y (3.781, <0.001), age >70 (0.118, 0.001), the use of TXA (3.52, <0.001), type of implant (6.055, <0.001), low postoperative Hg (0.333, <0.001), and yearly trend (Pearson: 0.322, <0.001). Factors associated with prolonged LOS included age <60y (0.641, 0.029), age >70 (1.723, 0.032), active cancer (0.256, 0.027), low postoperative Hg (1.674, 0.020), and postoperative transfusion (1.667, 0.015). Multivariate regression for factors associated with a home discharge showed aggregate significance for BMI <25 (0.886, 0.024), use of TXA (1.139, <0.001), type of implant (1.310, 0.008), age <60 (0.956, 0.004), and age >70 (−1.627, 0.036). Multivariate logistic regression for factors associated with a prolonged LOS showed aggregate significance for active cancer (−1.654, 0.015), postoperative transfusion (0.485, 0.023), and age >70 (0.600, 0.024). CONCLUSION. There has been a significant trend towards postoperative home-rehabilitation programs rather than inpatient rehabilitation following bilateral total knee arthroplasty. There has also been a trend towards an increasing age for those undergoing bilateral total knee arthroplasty. Factors predisposing patients towards non-home discharge disposition include increased age and female gender. The increased use of both TXA and patient specific implants has led to a decrease in operative time and postoperative transfusion rates, and thus a decrease in the overall length of inpatient hospital stay

Aims. Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients’ pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). Methods. This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. Results. The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). Conclusion. We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology. Cite this article: Bone Joint J 2024;106-B(3 Supple A):24–30

Aims. The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA. Methods. The National Inpatient Sample was queried for primary THAs (2008 to 2017) which were categorized into RA-THA, CA-THA, and M-THA. Past and projected use, demographic characteristics distribution, income, type of insurance, location, and healthcare setting were compared among the three cohorts. In-hospital complications, LOS, discharge disposition, and in-hospital costs were compared between propensity score-matched cohorts of M-THA versus RA-THA and M-THA versus CA-THA to adjust for baseline characteristics and comorbidities. Results. RA-THA and CA-THA did not exhibit any clinically meaningful reduction in mean LOS (RA-THA 2.2 days (SD 1.4) vs 2.3 days (SD 1.8); p < 0.001, and CA-THA 2.5 days (SD 1.9) vs 2.7 days (SD 2.3); p < 0.001, respectively) compared to their respective propensity score-matched M-THA cohorts. RA-THA, but not CA-THA, had similar non-home discharge rates to M-THA (RA-THA 17.4% vs 18.5%; p = 0.205, and 18.7% vs 24.9%; p < 0.001, respectively). Implant-related mechanical complications were lower in RA-THA (RA-THA 0.5% vs M-THA 3.1%; p < 0.001, and CA-THA 1.2% vs M-THA 2.2%; p < 0.001), which was associated with a significantly lower in-hospital dislocation (RA-THA 0.1% vs M-THA 0.8%; p < 0.001). Both RA-THA and CA-THA demonstrated higher mean higher index in-hospital costs (RA-THA $18,416 (SD $8,048) vs M-THA $17,266 (SD $8,396); p < 0.001, and CA-THA $20,295 (SD $8,975) vs M-THA $18,624 (SD $9,226); p < 0.001, respectively). Projections indicate that 23.9% and 3.2% of all THAs conducted in 2025 will be robotic arm- and computer-assisted, respectively. Projections indicated that RA-THA use may overtake M-THA by 2028 (48.3%) and reach 65.8% of all THAs by 2030. Conclusion. Technology-assisted THA, particularly RA-THA, may provide value by lowering in-hospital early dislocation rates and and other in-hospital metrics compared to M-THA. Higher index-procedure and hospital costs warrant further comprehensive cost analyses to determine the true added value of RA-THA in the episode of care, particularly since we project that one in four THAs in 2025 and two in three THA by 2030 will use RA-THA technology. Cite this article: Bone Joint J 2021;103-B(9):1488–1496

Aims. Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment. Methods. Prospectively collected data of TKAs performed at our institution’s two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA. Results. Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°). Conclusion. Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons’ decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: Bone Joint J 2020;102-B(6 Supple A):66–72

Aims. Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). Conclusion. The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102–107

Introduction. The association between preoperative opioid use and adverse outcomes after total hip arthroplasty (THA) has been reported. However, a quantitative assessment used to evaluate the combined effect of controlled substance use and define a threshold for adverse outcomes after THA has not been established. The current study aimed to identify the association between the NarxCare Score (NCS) (indicative of controlled substance use) and length of stay (LOS), discharge disposition, 90-day emergency department (ED) visits, readmission, and reoperation after primary THA, necessary to identify a preoperative NCS threshold for adverse outcomes. Methods. A total of 2,787 THAs (57.3% female; mean age: 64.3±11.14 years; NCS range: 0–800) were performed between November 2018-January 2020 at an integrated healthcare system with preoperative NCSs. Outcomes assessed included LOS, discharge disposition, 90-day ED visits, readmission (all-cause, procedure and non-procedure-related) and reoperation. The association between NCS category (in 100-point increments) and was analyzed through multivariate logistic regression accounting for risk factors. Results. NCS of zero, 1–99 and 100–199 were similar regarding all investigated outcomes (p>0.05 for all). Compared to a NCS of zero, NCS of 300–399 was independently associated with higher odds of a LOS >2 days (odds ratio [OR]:2.27; 95% confidence interval [CI][1.59–3.24]; p<0.001), non-home discharge (OR: 2.0; 95% CI [1.34–2.99]; p=0.001), 90-day all-cause readmission (OR: 2.0; 95% CI [1.16–3.36]; p=0.012). Furthermore, NCS of 300–399 exhibited higher odds of a procedure-related readmission (OR: 3.74; 95% CI [1.48–8.13]; p=0.004). There were no differences between the NCS strata in 90-day reoperation and non-procedure related readmission rates (p>0.05 for each). Conclusion. Higher NCS was associated with greater LOS and 90-day readmission, as well as lower odds of discharge to home. A NCS threshold of 300 can potentially designate high-risk patients for adverse outcomes after THA. This score may help stratify patients in the current alternative payment environment

Aims. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results. A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion. After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84

Background. Cementless femoral fixation in total hip arthroplasty (THA) continues to rise worldwide, accompanied by the increasing abandonment of cemented femoral fixation. Cementless fixation is known to contribute to higher rates of post-operative complications and reoperations. New data is available from the Centers for Medicare and Medicaid Services (CMS) regarding total costs of care from the Bundled Payment for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) initiatives. Questions/purposes. How does femoral fixation affect (1) 90-day costs; (2) readmission rates; (3) re-operation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing elective or non-elective THA?. Methods. We performed a retrospective review of 1671 primary THA cases in Medicare patients across nine hospitals in an academic healthcare network. CMS data was used to evaluate lump costs including the surgical admission and 30-day or 90-day post-operative episodes. Costs were then correlated with clinical outcome measures from review of our electronic medical record. Demographic differences were present between the cemented and cementless cohorts. Statistical analyses were performed including multiple regression models adjusted for the baseline cohort differences. Results. After controlling for confounding variables, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented femoral fixation also demonstrated a trend towards lower costs, fewer readmissions and shorter LOS. All of the reoperations within the early postoperative period occurred in cementless patients. Conclusion. In a large Medicare population, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperations. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation. Orthopaedic surgeons in training should become competent with femoral cementation technique

Introduction. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have focused on payer type and have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, elective, unilateral THA between January 2016 and June 2018. THA recipients were categorized as either Hospital Ambulatory Clinic Centers (HACC) with Medicaid as the primary payer or private office patients with a non-Medicaid primary payer based on a previous visit to our institution's HACC within the 6-months prior to surgery. Only patients who had been operated on by a surgeon with at least 10 HACC and 10 private office patients were included. Results. A total of 426 patients were included in this study, with 114 HACC and 312 private office patients. HACC patients were significantly younger (p<0.01), more likely to be black or “other” race (p<0.01), and more likely to be a current smoker (p<0.01). In the unadjusted model, length of stay (p=0.15) and surgical time (p=0.03) were greater in HACC patients. There was no difference in discharge disposition (p=1). After adjusting for patient risk factors, LOS was greater for HACC patients, whereas surgical time and facility discharge were lower. Conclusion. There was a significant difference in surgical time between HACC and private clinic patients. After controlling for patient risk factors, LOS, surgical time, and facility discharge were similar between the two groups. These results indicate that similar outcomes can be achieved for Medicaid patients as compared to non-Medicaid patients as long as the surgeon and patient care setting are similar. For any tables or figures, please contact the authors directly

Introduction. Robotic assisted Total Knee Arthroplasty (rTKA), provides surgeons with preoperative planning and real-time data allowing for continuous assessment of ligamentous tension and range-of-motion. Using this technology, soft tissue protection, reduced early post-operative pain and improved patient satisfaction have been shown. These advances have the potential to enhance surgical outcomes and may also reduce episode-of-care (EOC) costs for patients, payers, and hospitals. The purpose of this study was to compare robotic assisted vs. manual total knee arthroplasty: 1) 90-day episode-of-care (EOC) costs; 2) index costs; 3) lengths-of-stay (LOS); 4) discharge disposition; and 5) readmission rates. Methods. TKA procedures were identified using the Medicare 100% Standard Analytic Files including; Inpatient, Outpatient, Skilled Nursing (SNF) and Home Health. Members included patients with rTKA or manual TKA (mTKA) between 1/1/2016-3/31/2017. To account for potential baseline differences, propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual based on age, sex, race, geographic division, and comorbidities. After PSM, 519 rTKA and 2,595 mTKA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, discharge disposition and readmission rates were assessed. Results. Overall 90-day EOC costs were $2,391 less for rTKA patients ($18,568 vs. $20,960; p<.0001). Index facility cost and LOS were also less for rTKA patients by $640 ($12,384 vs. $13,024; p=.0001) and 0.7 days (p<.0001). Additionally, rTKA patients were discharged to SNF less frequently (12.52% vs. 21.70%; p<.0001) and home with health aid (56.65% vs. 46.67%; p<.0001) or self-care (27.55% vs. 23.62%; p=.0566) more frequently and had a 90-day readmission reduction of 33% (p=.0423). Conclusion. Robotic assisted TKA resulted in an overall lower 90-day episode-of-care cost when compared to manual TKA. The 90-day EOC cost savings of rTKA were driven by reduced facility costs, LOS and readmissions, and an economically beneficial discharge destination

In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples t-tests for continuous variables. A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06). Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ

Introduction. The advent of ambulatory total joint replacements has called for measures to reduce postoperative length of stay, while improving patient function and postoperative satisfaction. This prospective, randomized trial evaluated the efficacy of one-on-one preoperative physical therapy (PT) education with a supplemental web-based PT web-portal on discharge disposition, postoperative function and patient satisfaction after total joint replacement. Materials & Methods. Between February and June 2015, 126 patients underwent unilateral total knee (n=63) or total hip arthroplasty (n=63). All patients attended a group preoperative education (preopEd) class [standard of care] and were subsequently randomized into two groups. One group received no further education as per the standard of care [control; TKA= 31; THA=32] and the other received an in-person one-on-one preoperative PT education session (preopPTEd) as well as access to a web-portal during the postoperative period [experimental; TKA=32; THA=31]. Discharge disposition was attained from hospital records. Patient satisfaction and WOMAC scores were evaluated by a series of patient administered questionnaires. Results. The group that received preopPTEd trended towards a reduction in hospital length of stay compared to the current standard of care (2.4 days vs. 2.6 days; p=0.077). However, the group that received preopPTEd met the postoperative functional discharge requirements significantly faster (1.6 days vs. 2.7 days, respectively; p<0.001) and required fewer postoperative PT visits (3.3 vs. 4.4 visits respectively; p<0.001) than those who did not. With respect to satisfaction, patients who received the preopPTEd felt they were better prepared to leave the hospital postoperatively and were overall more satisfied with their postoperative education (p<0.001 and p<0.001, respectively). The majority (69.8%) of patients who did not receive preopPTEd reported that they would have benefitted from additional preopPTEd. There were no clinically relevant improvements in the WOMAC subscores or total score between the groups. All findings were consistent in both the TKA and THA sub-groups. Conclusion. Patients who received the preopPTEd required fewer PT visits and met the postoperative functional PT discharge criteria faster than those who did not. Patients who received preopPTEd also reported being better prepared to leave the hospital after surgery and better overall satisfaction compared to the current standard of care. The one-on-one preoperative PT education session with supplemental web-portal education pathway may be an adjunct to help reduce postoperative length of stay for ambulatory total joint replacements

Background. The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings. Methods. Using our institution's data, we calculated the mean cost per episode of care. We calculated the percent reduction in target price and percent savings or losses per case for the CJR and Bundle Payment Care Initiative (BPCI) for each Medicare Severity Diagnosis Related Group (MS-DRG) using mean cost per episode and CJR and BPCI target prices. We compared the target prices, annual savings, and losses per episode of care for both CJR and BPCI. All CJR savings, projected and actual, were computed by comparing CJR savings to that of 2018 BPCI savings. Results. We found an average savings of 2.32% under CJR compared to the projected loss of −11.6% for MS-DRG 469 with fracture. There was a 7.97% savings for MS-DRG 470 without fracture compared to the projected 1.9%, a 20.94% savings for MS-DRG 470 with fracture compared to the projected 23.7%, and a loss of −3.98% for MS-DRG 469 without fracture compared to the projected 2.5% savings. Conclusions. The CJR target prices are lower than that of BPCI and this makes maintaining an episode of care at or below the target price increasingly difficult. Discharge disposition and readmission are well established factors that increase hospital cost [7]. However, reduction of these does not seem enough to maintain savings under the CJR model. New cost savings mechanisms such as identification of patients eligible for SDD, and reduction of unnecessary home services resulted in smaller losses of positive margins, though these were still significantly less for CJR than BPCI

Introduction. There is debate regarding whether the use of computer-assisted technology, such as navigation and robotics, has any benefit on clinical or patient reported outcomes following total knee arthroplasty (TKA). This study aims to report on the association between intraoperative use of technology and outcomes in patients who underwent primary TKA. Methods. We retrospectively reviewed 7,096 patients who underwent primary TKA from 2016–2020. Patients were stratified depending on the technology utilized intraoperatively: navigation, robotics, or no technology. Patient demographics, clinical data, Forgotten Joint Score-12 (FJS), and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) were collected at various time points up to 1-year follow-up. Demographic differences were assessed with chi-square and ANOVA tests. Clinical data and mean FJS and KOOS, JR scores were compared using univariate ANCOVA, controlling for demographic differences. Results. During the study period, 287 (4%) navigation, 367 (5%) robotics, and 6,442 (91%) manual cases were performed. Surgical time significantly differed between the three groups (113.33 vs. 117.44 vs. 102.11 respectively; p<0.001). Discharge disposition significantly differed between the three groups (p<0.001), with a greater percentage of patients who underwent manual TKA discharged to a skilled nursing facility (12% vs. 8% vs. 15%; p<0.001) than those who had intraoperative technology utilized. FJS scores did not statistically differ at 3-months (p=0.067) and 1-year (p=0.221) postoperatively. There was a significant statistical difference in three-month KOOS, JR scores (59.48 vs. 60.10 vs. 63.64; p=0.001); however, one-year scores did not statistically differ between the three groups (p=0.320). Mean improvement in KOOS, JR scores preoperatively to one-year postoperatively was significantly largest for the navigation group and least for robotics (27.12 vs. 23.78 vs. 25.42; p<0.001). Conclusion. This study demonstrates shorter mean operative time in cases with no utilization of technology and clinically similar patient reported outcome scores associated with TKAs performed between all modalities. While the use of intraoperative technology may aid surgeons, it has not currently translated to better short-term patient outcomes

Introduction. The use of intraoperative liposomal bupivacaine (LB) peri-articular injection has been highly debated for total knee arthroplasty (TKA). We evaluated the effect of an institutional-wide discontinuation of intraoperative LB on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Material and Methods. Between July 1, 2019 and November 30, 2019, an institutional policy discontinued use of intraoperative LB, while the volume of non-LB with epinephrine was increased from 40-ml to 60-ml. A historical cohort was derived from patients undergoing TKA between January 1, 2019 and June 30, 2019. All patients received the same opioid sparing protocol, minimizing variability in prescribing habits. No adductor canal blocks/pumps were utilized. Nursing documented verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Opiate administration events were derived as Morphine Milligram Equivalences (MMEs) per patient per 24-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) tool was utilized. All time events were calculated relative to TKA completion instant. Results. 789 primary TKAs did not receive intraoperative LB, while 888 patients acted as controls. Age was significantly greater in patients that did not receive intraoperative liposomal bupivacaine (66.80±8.97 vs 65.57±9.46; p<.01). Gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were similar between the two groups (p>.05). Compared to historical controls, discontinuation of LB demonstrated no significant difference in postoperative inpatient VRS pain scores up to 72 hours (p>.05), opioid administration up to 96 hours (p>.05), or AM-PAC scores within the first 24 hours (p>.05). Discussion. Subjective pain scores, opioid consumption, and functional scores were unchanged in the early postoperative period following the discontinuation of intraoperative liposomal delivery of bupivacaine in TKA

Summary Statement. Navigated total knee arthroplasty (TKA) is becoming increasingly popular in the United States. Compared to traditional unnavigated TKA, the use of navigation is associated with decreased blood transfusions and shorter hospital stays. Introduction. Navigated total knee arthroplasty (TKA) is a recent modification to standard TKA with many purported benefits in regards to component positioning. Controversy currently exists though regarding its clinical benefits. The purpose of this study was to assess recent national trends in navigated and unnavigated total knee arthroplasty and to evaluate perioperative outcomes for each group. Methods. International Classification of Disease - 9th Revision (ICD-9) procedure codes were used to search the National Hospital Discharge Survey (NHDS) for all patients admitted to US hospitals after navigated and unnavigated TKA for each year between 2005 and 2010. Data regarding patient demographics, hospitalization length, discharge disposition, blood transfusions, deep vein thrombosis, pulmonary embolism, mortality, and hospital location were gathered from the NHDS. Trends were evaluated by linear regression with Pearson's correlation coefficient (r) and statistical comparisons were made using Student's t-test, z-test for proportions, and chi-square analysis with a significance level of 0.05. Results. 22,443 patients admitted for TKA were identified. 578 (2.6%) of these patients had a TKA utilizing navigation. After adjusting for fluctuations in annual TKA performed, the use of navigation in TKA demonstrated a strong positive correlation with time (r=0.71), significantly increasing from an average utilization rate of 2.2% between 2005–2007 to 3.2% between 2008–2010 (p<0.01). The location of the hospital was found to significantly impact the utilization of navigation, with the lowest rate seen in the Midwest region (2.0%) of the US and the highest rate seen in the South region (3.0%). The mean age of navigated patients was 66.0 years. This group included 211 men and 367 women. The unnavigated group had a mean patient age that was insignificantly higher at 66.4 years (p=0.37) and included 7,815 men and 14,047 women. Gender was also not significantly different (p=0.71) between those with navigated TKA and those with unnavigated TKA. The number of medical co-morbidities was significantly higher in those with navigation (mean 5.4 diagnoses) than those without navigation (mean 5.1 diagnoses, p=0.01). Average hospitalization length also varied based on navigation status, with significantly shorter stays for those with navigation (3.3 days, range 1–11) compared to those without (3.6 days, range 1–73, p<0.01). The rate of blood transfusion was significantly lower in the navigated group (13.0%) versus the unnavigated group (17.4%, p<0.01). There was no difference in the rate of deep vein thrombosis (0.69% vs 0.53%, p=0.64) or pulmonary embolism (0.17% vs 0.47%, p=0.10). Mortality was also not significantly different for navigated TKA (0.17%) when compared to unnavigated TKA (0.08%, p=0.61). Discharge disposition did not significantly vary based on navigation status either, with 65.5% of navigated patients and 67.0% of unnavigated patients able to go directly home (p=0.55) after their inpatient stay. Discussion/Conclusion. This study demonstrates that the use of navigated TKA in the US is rising. Additionally, despite having more medical co-mobidities, the navigated population required less blood transfusions and shorter lengths of stay. Interestingly, navigation utilization demonstrated variability based on hospital region. The reasons for this are not immediately clear, but may be related to differences in regional training