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

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

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

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. Current CMS reimbursement policy for total joint replacement is aligned with more cost effective, higher quality care. Upon implementation of a standardized evidenced-based care pathway, we evaluated overall procedural costs and clinical outcomes over the 90-day episode of care period for patients undergoing TKA with either conventional (Conv.) or robotic-assisted (RAS) instrumentation. Methods. In a retrospective review of the first seven consecutive quarters of Bundled Payment for Care Improvement (BPCI) Model 2 participation beginning January 2014, we compared 90-day readmission rates, Length of Stay (LOS), discharge disposition, gains per episode in relation to target prices and overall episode costs for surgeons who performed either RAS-TKA (3 surgeons, 147 patients) or Conv. TKA (3 surgeons, 85 patients) at a single institution. All Medicare patients from all surgeons performing more than two TKA's within the study period were included. An evidence-based clinical care pathway was implemented prior to the start of the study that standardized pre-operative patient education, anesthesia, pain management, blood management, and physical/occupational therapy throughout the LOS for all patients. Physician specific target prices were established from institutional historical payment data over a prior three year period. Results. RAS and Conv-TKA procedures exhibited an average gain per episode of $7,600 and $5,579, respectively. The average total cost per 90-day episode was $2,085 lower for patients receiving RAS-TKA ($28,943 versus $31,028), with the majority of cost savings in reduced SNF usage ($1,481) and readmissions ($944). Discharge to home versus Sub-acute Rehabilitation Facilities (SAR's) was 14% higher in the RAS group (62% vs 48%, p<0.05). Conclusions. Implementation of a standardized care pathway across all service departments and physicians resulted in a reduction in overall episode of care costs, with further reductions in cost and discharge to SARs observed with the use of RAS

Background. Manually instrumented knee arthroplasty is associated with variability in implant and limb alignment and ligament balance. When malalignment, patellar maltracking, soft tissue impingement or ligament instability result, this can lead to decreased patient satisfaction and early failure. Robotic technology was introduced to improve surgical planning and execution. Haptic robotic-arm assisted total knee arthroplasty (TKA) leverages three-dimensional planning, optical navigation, dynamic intraoperative assessment of soft tissue laxity, and guided bone preparation utilizing a power saw constrained within haptic boundaries by the robotic arm. This technology became clinically available for TKA in 2016. We report our early experience with adoption of this technique. Methods. A retrospective chart review compared data from the first 120 robotic-arm assisted TKAs performed December 2016 through July 2018 to the last 120 manually instrumented TKAs performed May 2015 to January 2017, prior to introduction of the robotic technique. Level of articular constraint selected, surgical time, complications, hemoglobin drop, length of stay and discharge disposition were collected from the hospital record. Knee Society Scores (KSS) and range of motion (were derived from office records of visits preoperatively and at 2-weeks, 7-weeks and 3-month post-op. Manipulations under anesthesia and any reoperations were recorded. Results. Less articular constraint was used to achieve balance in the robotic group, with a higher incidence of cruciate retaining retention (92% vs. 55%, p < 0.01) and a trend towards lower use of varus-valgus constrained articulations (5% vs. 11%, p = 0.068). Robotic surgery increased mean operative time by 22 minutes (p < 0.001). Operative time improved by 26 minutes from the first 10 robotic cases to the last 10 robotic cases. The robotic group had a lower hospital length of stay (2.7 vs. 3.4 days, p < 0.001). Discharge home was not significantly different between robotic and manual groups (89% vs. 83%, p = 0.2). Postoperative Knee Society scores were similar between groups at each postoperative time interval. Robotic-arm assisted TKA patients demonstrated lower mean flexion contracture at 2-weeks (1.8 vs. 3.3 degrees, p < 0.01), 7-weeks (1.0 vs. 1.8 degrees, p <0.01), and 3-months (0.6 vs 2.1 degrees, p = 0.02) post-surgery, but these differences were small. Mean flexion did not differ between groups at 3-month follow-up, but motion was achieved with a significantly lower rate of manipulation under anesthesia in the robotic group (4% vs 17%, p = 0.013). Conclusion. Preliminary findings demonstrate robotic-arm assisted TKA is safe and efficacious with outcomes comparable, if not superior, to that of manually instrumented TKA. Keywords. total knee arthroplasty, robotic arm-assisted total knee arthroplasty. For any figures or tables, please contact authors directly

Introduction. Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) helps restore range of motion. This study identifies MUA risk factors to support early interventions to improve functionality. Methods. Data was retrospectively reviewed in 2,925 primary TKAs from October 2013 through December 2015 from 13 orthopedic surgeons using hospital and private practice electronic medical records (EMR). Statistical analysis evaluated MUA and non-MUA groups, comparing demographic, operative, hospital-visit, and clinical factors. T-test, chi-square test, ANOVA and regression analysis were performed. Significance was set at p<0.05. Results. Of 2,925 TKAs, 208 MUAs were performed (7.1%) with no significant differences between groups in sex, BMI, or diabetes status. Mean age of the MUA group was 61.98 years old, and 66.89 years old in the non-MUA group (p<0.005). The ratio of MUA patients with high cholesterol was 3.37% (7/208), and 1.10% (30/2717) in the non-MUA group (p=0.014). The ratio of African-American patients in the MUA group was 6.73% (14/208), and 2.94% (80/2717) in the non- MUA group (p=0.003). Of cases with device data recorded in the EMR (n=1890), MUA incidence in patients receiving a cruciate-retaining (CR) device was 14.58% (50/343), and 9.57% (148/1547) in patients receiving a posterior-stabilized (PS) device (p=0.006). A CR-device patient was 52.35% more likely to undergo MUA than a PS-device patient (95% CI, 1.13–2.05). MUA rate by surgeon training was 6.7% for joint fellowship, 6.8% for general fellowship, and 12.0% for sports medicine fellowship (p=0.015). Further analysis showed that rate of CR-device use was 13.3% for joint-fellowship trained surgeons, 10.2% for general fellowship, and 74.7% for sports medicine fellowship (p<0.001). With the numbers available for this investigation, there were no significant differences found between groups in relation to surgeon, high-volume (>150 TKAs annually) or low-volume surgeons, length of stay, discharge disposition, or smoking status. Conclusion. MUA risk factors include a lower mean age, high cholesterol, African-American, surgeon fellowship training, and receiving a cruciate-retaining device

Introduction. Total joint arthroplasty (TJA) is projected to be the most common elective surgical procedure in the coming decades, however TJA now accounts for the largest expenditure per procedure for Medicare and Medicaid provided interventions. This is coupled with increasing complexity of surgical care and concerns about patient satisfaction. The Perioperative Surgical Home (PSH) model has been proposed as a method to both improve patient care and reduce costs. The PSH model provides evidence-based protocols and pathways from the time of surgical decision to after postoperative discharge. PSH pathways can further be standardized with integration into electronic medical records (EMRs). The purpose of this study is to see if the implementation of PSH with and without EMR integration effects patient outcomes and cost. Methods. A retrospective review was performed for all patients who underwent elective primary total joint arthroplasty at our institution from January 1, 2012 to April 1, 2018. Three cohorts were compared. The first cohort included patients before the implementation of the PSH model (January 1, 2012 - December 31, 2014). The second cohort included patients in the PSH model without EMR integration (January 1, 2015 – August 1, 2016). The third cohort included patients in the PSH model with EMR integration (August 1, 2016 - April 1, 2018). The clinical outcome criteria measured were average hospital length of stay (LOS), 30-day readmission rates, and discharge disposition. Financial data was collected for each cohort and primary measurements included average total cost, diagnostic cost, anesthesia cost, laboratory cost, room and board cost, and physical therapy cost. Results. Overall, 3,384 primary total joint arthroplasty cases were included. Implementation of a PSH without EMR significantly reduced LOS (1.79 vs 3.59, p<0.05), readmission rates (1.9% vs 4.3%, p<0.05), and decreased the rate of skilled nursing facility (SNF) disposition (15.2% vs 31.1%, p<0.05) and increased discharge to home care (84.8% vs 68.9%, p<0.05). EMR integration did not significantly reduce LOS or readmission rates but did further decreased the rate of SNF disposition (10.2% vs 15.2%, p<0.05), while increasing the rate of home care disposition (89.8% vs 84.8%, p<0.05). Per case, implementation of the PSH model without EMR integration decreased diagnostic cost (−$9.37, p<0.05), anesthesia cost (−$71.34, p<0.05), room and board cost (−$285.18, p<0.05) and total overall cost (−$1432.38, p<0.005). Integrating pathways into an EMR led to further cost-reduction in laboratory cost (−$47.04, p<0.05), physical therapy cost (−$57.79, p<0.05), and total overall cost (−$2,837.28, p<0.05). EMR integration did not lead to significant increases in other cost variables. Conclusions. The implementation of a PSH model for total joint arthroplasty, especially with electronic medical record integration, reduces cost, average LOS, 30-day readmissions, and increases discharge to home care

INTRODUCTION. Early discharge after total joint arthroplasty has started to gain acceptance in select academic centers. The purpose of this study was to compare the risk of readmission of Medicare patients discharged one day after total knee arthroplasty (TKA), versus those discharged two or three days after surgery. Our hypothesis was that patients with length of stay (LOS) of one day would not have a higher risk of readmission in a community setting. METHODS. A hospital impatient database was queried for all unilateral, primary total knee replacements performed on patients 65 years or older from January 1, 2013 to December 31, 2014. A total of 1,117 patients discharged the day after TKA (reduced LOS) were compared with 947 patients discharged POD #2 or 3 (traditional LOS). All cases were performed at a community-based joint replacement center with rapid recovery protocols. Discharge timing and disposition were based on established functional benchmarks judged by physical therapy. The main outcome measure was all-cause 30-day readmissions. Multivariate logistic regression was used to calculate odds ratio for all cause 30-day readmission for reduced versus traditional LOS while controlling for age, gender, race, diabetes mellitus, ASA score (less than 3 versus 3 or greater), discharge disposition (home versus rehab). RESULTS. The 30-day readmission rate for the reduced LOS group was 1.2%, as compared to 3.4% readmission rate for the traditional LOS group (p=.001). In the regression model, the traditional LOS group had an increased risk of readmission (odds ratio 2.10, 95% CI 1.02–4.35, p=0.045) when controlling for confounding factors. DISCUSSION AND CONCLUSIONS. Medicare patients can be discharged safely the day after total knee arthroplasty with no increased risk of 30-day readmission in a community medical center

Background. The Perioperative Surgical Home (PSH) is a multi-disciplinary rapid recovery pathway aimed at transforming surgical care by delivering value and improving outcomes and patient satisfaction. Our institution developed a PSH pathway for total hip arthroplasty (THA) patients in March 2014. The Orthopaedic and Anesthesia Services co-managed the patients throughout the entire surgical process. Weekly meetings were held to discuss medical and social requirements for upcoming patients including disposition planning. All patients received day of surgery physical therapy, and anesthesia post-surgical pain control and medical co-management. We hypothesized that the PSH would provide enhanced care for THA patients. To our knowledge this is the first report on the PSH in a total joint population. Methods. We prospectively followed 180 THA patients from the PSH group (SH) and compared them to a group matched for age, body mass index (BMI), American society of anesthesiologist score (ASA), and Charleson comorbidity index score (CCI) that were not involved in the PSH (NSH). We used Wilcoxon, Chi square, and multivariate analysis to compare the groups for length of stay (LOS), total direct cost (TDC), complications, readmissions at 30 days, and discharge disposition location. Results. No significant difference was found between the two cohorts with respect to age, BMI, ASA, or CCI. The average age, BMI, ASA and CCI were 64, 30, 2.5, and 3.6. The average LOS of the SH cohort was 2.1 days which was significantly lower than the NSH cohort at 3.6 days (P<0.001). Significantly more patients were discharged to home in the SH group, 83% versus 71% in the NSH group (P=0.006) regardless of age (P=0.003) and ASA (P=0.048). No significant difference was found between the two groups with regard to complications (P=0.346), TDC (P=0.883), or readmissions at 30 days (P=0.637). Discussion. The implementation of the PSH led to decreased length of stay and allowed more patients to be discharged to home, without an increase in complications or readmissions. We were able to accomplish this in patients with higher ASA and CCI scores which has not been the case in other rapid recovery programs. Effective care pathways require contribution and cooperation by multiple healthcare personnel throughout the phases of patient care. We feel that key factors contributing to the success of the PSH include post-surgical co-management by anesthesia, early physical therapy, and weekly meetings to discuss patients’ individual needs for disposition

Introduction:. The direct anterior approach for total hip arthroplasty has shown to improve multiple early outcome measures. However, criticisms suggest improved results may be due to selection bias and protocol changes. This study compares mini-incision posterior approach to direct anterior approach performed by one surgeon, controlling for influences other than the surgical approach itself. Methods:. An IRB approved retrospective review was conducted on 150 consecutive primary total hip arthroplasty patients; the first 50 from mini-incision posterior approach, followed by 50 during the learning curve for direct anterior approach, and 50 subsequent cases when the approach was routine. Peri-operative protocols were alike for all groups. Data collection included patient demographics, anesthesia, operative times, discharge disposition, length of stay, VAS pain scores, progression from assistive devices, and narcotic use at follow-up of two and six weeks. Statistical methods included Wilcoxon rank sum, ANOVA, Kruskal-Wallis, chi-square, fisher exact and t-tests. P-value of <.05 was considered significant. Results:. The groups were well-matched for demographics. The anterior group trended towards higher age, BMI, ASA and pre-op VAS scores. Factors favoring the anterior group reaching statistical significance included: decreased length of stay of 1.02 (learning curve) and 1.26 (routine) days (p < .0001); discharge to home instead of a rehab facility, 80% and 84% anterior versus 56% posterior (p = 0.0028); VAS pain scores at two weeks 2.7 and 2.2 anterior versus 5.2 posterior (p < .0001); less narcotic pain medication use at two weeks, 44% and 30% versus 86% (p < .0001). In the anterior groups, walker use was less at two weeks, 20% and 12% versus 74% (p < .0001) and at six weeks, 4% and 2% versus 20% (p=.0018). Conclusion:. Primary total hip arthroplasty using the anterior approach versus the posterior approach allows for more rapid recovery in patients with no significant selection bias or protocol changes, even during the learning curve period

Background. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardisation of care on short-term post-operative outcomes and resource utilisation in lower-extremity total joint arthroplasty. Methods. An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first 30 days after discharge. Hierarchical models were used to estimate effects of hospital and surgeon procedure volume and standardisation on individual and combined surgical outcomes and length of stay. Results. After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality and lower risk of readmission and higher likelihood of being discharged home. The impact of process standardisation was substantial; maximising adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusion. Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardisation is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established. However, our findings suggest that process standardisation could help providers optimise quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume

Background. Fifteen to twenty percent of patients presenting for total hip arthroplasty (THA) have bilateral disease. While simultaneous bilateral THA is of interest to patients and surgeons, debate persists regarding its merits. The majority of previous reports on simultaneous bilateral THA involve patients in the lateral decubitus position, which require repositioning, prepping and draping, and exposure of a fresh wound to pressure and manipulation for the contralateral THA. The purpose of this study was to compare complications, component position, and financial parameters for simultaneous versus staged bilateral THAs using the direct anterior approach (DAA). Methods. Medical records were reviewed for patient demographics, medical history, operative time, estimated blood loss (EBL), change in hemoglobin, transfusion, tranexamic acid (TXA) use, length of stay (LOS), discharge disposition, leg length discrepancy, acetabular cup position, and perioperative complications. Cost and reimbursement data were analyzed. Results. Forty-four patients were included in the sequential group and fifteen patients in the simultaneous group (Figure 1). Operative time was significantly longer for simultaneous DAA THA, with procedures lasting 260 +/− 48 minutes compared to 132 +/− 30 minutes for a single arthroplasty in the sequential group (p<0.001). Patients undergoing simultaneous bilateral DAA THA also had a significantly higher EBL (p<0.001), hemoglobin drop (p<0.001), and blood transfusion rate (p<0.01) compared to parameters for a single arthroplasty in the sequential group. This was despite TXA being used in a significantly higher proportion of simultaneous procedures compared to sequential procedures (p<0.01). The LOS was significantly longer in patients undergoing simultaneous bilateral DAA THA (2.9 +/− 1.0 days) compared to sequential (2.2 +/− 0.6 days) (p<0.001). No deep venous thrombosis (DVT) or pulmonary embolism (PE) was detected in either group during the observation period. No significant difference was detected regarding perioperative complications or whether patients were able to be discharged home instead of to a post-inpatient facility (Figure 2). There was no significant difference in component position, complications, or readmissions between groups. Total cost per hip was significantly less for the simultaneous ($15,565 +/− 1,470) compared to the sequential group ($19,602 +/− 3,094) (p<0.001). There was no significant difference in total payments between the simultaneous group ($25,717 +/− 4,404) and the sequential group ($24,926 +/− 8,203) (p=0.93). Thus, with lower cost and similar reimbursement, profit per hip was significantly higher for the simultaneous ($9,606 +/− 5,060) compared to the sequential group ($5,324 +/− 7,997) (p<0.05). (Figure 3). Conclusions. Significant data regarding simultaneous bilateral THA has been published but results are conflicting and different surgical approaches were used. To our knowledge only four previous reports have been published examining simultaneous bilateral THA performed via the DAA. While simultaneous DAA THA presents challenges, our results suggest that simultaneous DAA THA may add value to the healthcare system without resulting in increased complications compared to sequential hip arthroplasty

Purpose:. Total knee and hip arthroplasty is a commonly performed surgical procedure. As the population ages the numbers of these procedures are predicted to increase. Maximizing patient outcomes and decreasing healthcare delivery costs will be essential to creating a higher value U.S. healthcare system. The purpose of our study was to analyze the effect of a multidisciplinary preoperative education program (Joint Academy) on various outcomes that effect overall cost of primary hip and knee arthroplasty. Methods:. A retrospective review of 904 patients' charts that underwent primary total hip and knee arthroplasty from October 1, 2010 to September 31, 2011 at a single institution was performed. We then compared 102 patients who did not have preoperative education to 802 patients who did have preoperative education through the Joint Academy (JA). We looked at patient length of stay (LOS), discharge disposition, and internal hospital cost. Linear regression was performed on all data to look for statistical significance. Results:. We found that those patients that participated in JA had a length of stay that was 2.12 days less than those that did not participate in the Joint Academy. We also found that in the JA group, patients were 62% more likely to be discharged to home versus patients in the non-JA group. We also found that the JA group had lower internal hospital costs; with the JA group on average costing $1,493 less than the non-JA group. All referenced findings were statistically significant. Conclusion:. When looking at future global or episodic payment plans in the future all costs of care delivery will be scrutinized. To our knowledge internal hospital costs have not been evaluated in any other studies in regards to preoperative patient education. The decrease in variable costs seen at our institution with JA patients may help justify the benefit of allocating resources to preoperative patient education programs and in turn decrease the overall cost of hip and knee arthroplasty. Significance: The Joint Academy decreased patient length of stay, improved their chances of discharge to home, and decreased internal hospital costs. Multidisciplinary preoperative patient education may provide a cost efficient means to reduce overall healthcare cost and improve a patient's ability to return home more quickly