Introduction. Morbid obesity (BMI>40) is a significant risk factor for complications following total joint arthroplasty (TJA). As such many have a restrictive practice of withholding elective primary TJA in the morbidly obese. The purpose of this study was to observe the implications of this practice. Methods. From 2012 to 2014, 289 patients with morbid obesity and end-stage OA of the hip or knee were prospectively followed. At initial visit, patients were given a packet on risks of TJA in the morbidly obese and referral information to a weight loss clinic. Patients were contacted at 6, 12, 18 and 24 months from initial visit for PROs, and BMI changes. The average age of patients was 56 (26.7–79.1) there were 218 females and 71 males. Results. The average BMI at initial visit was 46.9 (39.9–68.2). 85 patients (29%) refused additional follow up or to answer phone surveys regarding their status. 146 patients (50.5%) have not had surgery. Initial BMI in this cohort was 47.4 (39.9–68.6) and at last follow up was 46.8 (28.9–70.8). Of those, 11 (7.5%) had a last follow up BMI≤40. Only 23% of patients went to the bariatric clinic and 13% had bariatric surgery. Fifty-eight patients (20.1%) underwent TJA. BMI at initial visit was 45.3 (40.3–55.4), and at the time of surgery was 41.3 (27.5–69.5). Only 20 patients (6.9% of those followed) have successfully achieved BMI < 40 and had surgery. Of those, 14 (70%) had a last follow up BMI≤40, and 2 (10%) had a last follow up BMI≤30. Conclusions. The practice of restricting total joint replacement to morbidly obese patients does not serve as an incentive to lose weight prior to arthroplasty. Only 20% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and collaborative care among specialties is required to optimize patients prior to surgery

Introduction. There is little published evidence regarding cannabis or cannabinoid use among orthopedic patients, yet there is increasing public attention on its possible role in treating various medical conditions including pain. California passed legislation legalizing cannabis for medical treatment in 2003 and recreational use in 2018. All patients undergoing total joint arthroplasty (TJA) at our institution are screened preoperatively with a urine toxicology (UTox) screen. Though a positive test for other substances triggers surgery cancellation, a positive screen for cannabis and/or opiates does not impact whether surgery is performed. We sought to quantify the prevalence of cannabinoid and opioid use among patients with chronic pain from end-stage hip and knee osteoarthritis who underwent arthroplasty at our institution in 2012 and 2017. Methods. Institutional Review Board approval was obtained. A retrospective chart review was performed for all patients with severe arthritis who underwent total hip and knee arthroplasty (THA and TKA) at our institution during the calendar years 2012 and 2017. Patients were excluded if TJA was performed for acute trauma or if no pre-operative UTox screen was obtained. The UTox screen was used to determine preoperative cannabis and opioid use. Chi-squared testing was performed, and significance was defined as p<=0.05. Results. In the two years studied, 546 of 560 primary TJA surgeries (98%) had a pre-operative UTox screen performed. These 546 operations in 525 patients were reviewed (359 TKAs and 187 THAs). Comparing 2012 to 2017, the prevalence of preoperative cannabis use increased from 9% to 15% (p =.05) while the prevalence of opioid use decreased from 24% to 17% (p=.04). The proportion of patients who tested positive for both cannabis and opioids was low (3%) and did not change between 2012 and 2017 (p=.50). With the numbers available, patients who were using cannabis were no more or less likely to be taking opioids than non-cannabis users (p=.24). Discussion and Conclusion. To our knowledge, this is the first study to identify the prevalence and trends of cannabis use in patients undergoing TJA. At our institution, cannabis use increased more than 60% while opioid use decreased about 30% over a 5-year interval. Whether these findings are related remains unclear. Future directions will include studying postoperative opioid requirements, disposition, complications, and readmissions in TJA patients who use cannabis

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 ambulatory surgery centers which will be subjected to even further decreases in net revenue per patient