Introduction. Rapid recovery protocols (RRP) for joint replacements have been shown to improve efficiency, reduce costs, and minimize adverse outcomes in academic health systems. The purpose of this study is to evaluate if RRP can be safely implemented in a community health system for total knee arthroplasty. Methods. This study used a retrospective cohort of 3,608 patients who underwent primary unilateral total knee arthroplasty from January 1, 2013 to December 31, 2014. 60 Patients were excluded because data or surgery could not be verified: BMI less than 18.5 or greater than 60 kg/m∘2 or if the surgical time was less than 45 seconds or greater than 180 minutes, and bilateral surgery. Data was obtained from querying the health system's inpatient database containing information for all joint replacements within the system. Patients were compared in two groups: those who received a RRP after surgery versus those who received traditional post-op care. The main outcome measure was all-cause 30-day readmissions. Multivariate logistic regression was used to calculate the odds for all-cause 30-day readmission for patients who received RRP versus traditional care when controlling for age, gender, race, insurance status (Medicare versus no Medicare), obesity, diabetes, renal disease, tobacco use, and ASA score (less than 3 versus 3 or greater). Results. Patients receiving RRP were readmitted less than those who received traditional care (1.6% versus 3.6%, p<0.001) and had a lower mean length of stay (1.5 versus 3.3 days, p<0.001). When controlling for confounding factors, the odds of 30-day readmission for patients receiving RRP versus traditional care was 0.42 (95% CI 0.26–0.66, p<0.001). Conclusions. Rapid recovery protocols are an effective means of reducing 30-day readmissions and length of stay in patients undergoing primary unilateral total knee arthroplasty in a community setting

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. ERAS allows for the incorporation of evidence based practices and incorporated a comprehensive assessment of the patient's journey through the surgical process from pre-operative screening through to post-operative care. The purpose of this study was to determine if optimisation of ERAS protocol with pre-operative screening and incorporating patient-specific factors into their post operative care would improve length of stay (LOS) and readmission rates following total joint arthroplasty (TJA) in a Canadian community hospital setting.

The study collected clinical, demographic data and the physical status perioperative using the American Society of Anaesthesiologists (ASA) classification on 508 patients who underwent TJA between January and August 2015 and compared similar data from the same time frame in the previous calendar year prior to implementation of the pathway. Cohorts were analysed for length of stay (LOS), readmission rates, Pre-operative assessments (completed by anaesthesia, nursing and pharmacy), relevant labs, patient history (surgery, medical, social), and patient values were all considered when developing a specific patient plan for care post-operatively. A post-operative management tool was used to optimise pain control, post-operative nausea and vomiting, bowel management, diabetes blood glucose control, venous thromboembolism prophylaxis, as well as monitoring parameters specific to patient medical history (e.g. respiratory, cardiac). While in hospital, physiotherapy and nursing were consulted by the pharmacist to assess whether patient's post op management needed to be altered to optimise mobilisation and recovery in hospital. The average patient's LOS and readmission rates in 30 days was analysed to assess the change after implementation of the post-operative management tool based on patient specific factors.

A total of 508 patients (mean age: 66 years), ASA classification was 3 or greater for 430 patients. The patients were assessed for LOS, readmission rates in 30 days. The mean LOS decreased from 3.6 to 3.3 days after optimisation of the ERAS protocol (student t test p=0.021). The 30-day readmission rate decreased from 2.9% to 1.4% post intervention (z test p=0.087) when compared to the same time period in the previous calendar year prior to protocol implementation. Overall, the cost savings to optimising the ERAS protocol for the hospital is substantial; with approximately $238 saved per patient.

Pre-operative screening and incorporating patient-specific factors into an individualised care plan to optimise the ERAS protocol for TJA reduced mean length of stay without a concomitant increase in readmission rates with significant cost saving.

Introduction. Rapid recovery protocols after joint replacement have been implemented widely to decrease hospital length of stay (LOS). Minimally-invasive total knee arthroplasty (MIS-TKA) may facilitate rapid recovery for patients. Increased complications and LOS have been documented in morbidly obese TKA patients. The objective of the current study was to retrospectively evaluate the impact of morbid obesity on MIS-TKA patients. Methods. We conducted a retrospective chart review on patients that underwent MISTKA at a high volume orthopedic center between August 2012 and September 2015 (N = 4173). All surgeries were performed by one of six fellowship trained surgeons utilizing the same implant. MISTKA was performed utilizing a mid-vastus approach under tourniquet. All patients experienced rapid recovery protocols utilizing multi-modal pain management pathways, same day physical therapy, and absence of CPM machines. We evaluated patient age, gender, operative time, LOS, and 90-day readmission for morbidly obese (BMI≥40; n = 597), and non-morbidly obese (BMI<40; n = 3576) patients. Statistical analysis was conducted using Minitab 16 Statistical Software. Results. Morbidly obese patients had significantly higher mean LOS (1.74 days) compared to non-morbidly obese patients (1.62 days, p=0.035), and significantly higher 90-day readmissions (12.45% and 6.65% respectively, p= 0.001). In patients over the age of 65, with BMI under 40, females had significantly higher mean LOS than males (1.70 and 1.47 days respectively, p< 0.001). And in non-morbidly obese patients under the age of 65, females still experienced significantly higher mean LOS compared to males (1.35 and 1.11 days respectively, p<0.001). Conclusions. Our findings indicate that despite implementation of rapid recovery protocols, morbidly obese patients experienced significantly higher LOS than non-morbidly obese patients. Compared to their male counterparts, non-morbidly obese female patients had significantly higher LOS

Over the past fifteen years, the average length of stay for total hip (THA) and total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and peri-operative protocols. Rapid recovery techniques and peri-operative protocols have been refined to allow for same-day discharge with improved outcomes. In addition to Rapid Recovery techniques for the clinical care of the outpatient, one critical component to same-day total knee arthroplasty is the efficient performance and simplicity of the procedure itself. Simplified instrumentation and elimination of modularity can provide that efficiency and simplicity. All polyethylene tibial components have been mostly supplanted by modular metal-backed designs in recent years. However, mounting evidence suggests that survivorship of TKA with an all-poly tibia is superior to TKA with metal-backed, modular designs in all age groups except younger than 55, in which survival is equal to a modular design. Furthermore, this survival advantage was unaffected by obesity. Combining these excellent clinical results with the efficiency of a non-modular component can add to the efficiency and simplicity of the surgical technique. Therefore, in outpatient total knee arthroplasty, the all-poly tibia truly represents the less is more mentality

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Introduction. There is no consensus on the ideal pain management strategy following total hip arthroplasty (THA). This study sought to identify immediate changes in the hospital course of patients undergoing primary THA following implementation of a rapid recovery anesthesia and multimodal management of pain (RAMP) protocol. For this study, rapid recovery anesthesia describes the use of preoperative non-narcotic medication in conjunction with neuraxial anesthesia techniques confined to the operating room only. The multimodal pain regimen consists of pre- and post-operative high dose nonsteroidal anti-inflammatories (NSAIDs), gabapentin, and antiemetics with or without intraoperative periarticular anesthetic injection. We hypothesized that the implementation of a RAMP protocol would lead to decreased reported pain scores, decreased narcotic use, and a shorter hospital stay in patients undergoing primary THA. Methods. This retrospective cohort study performed at a multi-surgeon high-volume institution reviewed the records of 81 consecutive patients who underwent primary THA utilizing traditional anesthesia and an opioid-dependentpain management techniques between June to September 2014 compared to 78 patients who underwent primary THA after implementation of the RAMP protocol between November 2014 to February 2015. The length of stay (LOS), pain scores, narcotic use, and other clinical data were recorded for each study group. Equality of variance was confirmed prior to statistical analysis using t-test for equality of means. Results. There was no significant difference in the demographics, body mass index, ASA classification, or Charleson Comorbidity Index between the two cohorts. The average LOS was significantly shorter after implementation of the RAMP protocol with a mean of 2.10 ± 1.1 days versus 2.89 ± 1.0 days. Total amount of narcotics used was significantly less with the RAMP protocol (Fig 1). Patient reported pain scores were improved throughout the hospital stay with patients receiving the RAMP protocol reporting significantly less pain beginning the morning of POD 1 (Fig 2). No significant decrease in kidney function was seen following the use of high dose NSAIDs (p=0.18). Conclusions. The implementation of a RAMP protocol in patients undergoing primary total hip arthroplasty has resulted in an immediate shorter length of stay with less narcotics use and improved reported pain scores. To our knowledge, this is the first study demonstrating a statistically significantly shorter length of stay associated with a multimodal pain protocol. This study supports the benefits of broad implementation a RAMP protocol for total hip arthroplasty

BACKGROUND. As the climate of medicine continues to change, physicians and healthcare administrations seek to improve both the quality of the care we provide patients, as well as reducing the cost at which we provide that care. Delivering value based care is of the utmost importance. The Perioperative Surgical Home (PSH) model is a multidisciplinary team approach to care that has shown success in reducing cost, length of stay, and admission to after care facilities. We sought to compare the results of total knee arthroplasty patients managed in the PSH rapid recovery model, to patients managed in a more traditional fashion. METHODS. We compared 451 patients managed in the PSH model from January 1 to December 31, 2015 to 453 patients managed in a more traditional fashion from January 1 to December 31, 2014. Preoperative. Once identified as potential candidates for total knee arthroplasty, a thorough triage process to optimize patients' medical co-morbidities, educate, and set expectations begins with an evaluation by the preoperative staff and mandatory attendance at a total joint class. Patients were sent for pre-operative physical therapy. Intraoperative. Neuraxial anesthesia was the anesthetic of choice, and perineural analgesia in the form of an adductor canal catheter and single shot posterior capsular injection were used to minimize pain and narcotic usage while maintaining the patient's ability to ambulate with physical therapy early in the post operative course. Additionally, multimodal analgesia was achieved with non- opioid analgesics (acetaminophen, NSAIDS, and gabapentanoids) and limited opioids. Aggressive fluid management and administration of steroids and ketamine also took place intraoperatively. Postoperatively. A multi-disciplinary team led by an orthopaedic surgeon and an anesthesiologist managed the patients throughout their stay. Multimodal analgesia was continued, and there was a rapid de-escalation of care. Physical therapy was initiated in PACU and continued at a minimum of BID thereafter. Patients were eligible for discharge on POD 1 after meeting physical therapy criteria. RESULTS. Average Length of Stay (LOS): 2.86 days in 2014 down to 2.1 in 2015 for an over 25% reduction. Discharge Mix: 71% to home independently or with home health in 2014 increased to 80% in 2015, with a reduction in discharges to a Skilled Nursing Facility from 24% to 16% respectively. 30 Day Readmissions: remained constant at 8 per year. Hospital Cost: $11,126.00 in 2014 vs $10,703.00 in 2015. CONCLUSION. As bundled payments began to change the financial climate of joint replacement surgery it is important to minimize costs and length of stay while continuing to improve care and outcomes. The PSH rapid recovery model delivers value based care that is well suited for this environment

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

Great strides have been made in perioperative pain management after total knee arthroplasty (TKA) leading to reduced length of hospital stay, cost reduction, improved patient satisfaction, and more rapid recovery without affecting the rates of readmission after surgery. To assure a happy patient, early recognition of patients at risk for persistent postoperative pain prior to surgery is key. Patients on chronic pain medication should be evaluated by pain management specialists with the intention of reducing overall narcotic requirement prior to TKA. Patients with high anxiety levels, pain catastrophizing, and Kinesphobia are at increased risk for increased pain and poor outcomes and should be referred for cognitive behavioral therapy and coping strategies. Finally, patients with hypersensitivity syndromes localised in the soft tissue around the knee should undergo desensitization protocols prior to TKA. Patient education on the risk of increased postoperative pain is crucial to manage expectations and optimise modifiable risk factors prior to TKA. To assure a happy patient indicated for TKA, a comprehensive pain management strategy divided into pre-, intra-, and post-operative periods should be employed

Introduction/Aim. The NAVIO robotic-assisted TKA (RA-TKA) application received FDA clearance in May 2017. This semi-active robotic technique aims to improve the accuracy and precision of total knee arthroplasty. The addition of robotic-assisted technology, however, also introduces another potential source of surgery-related complications. This study evaluates the safety profile of NAVIO RA-TKA. Materials and Methods. Beginning in May 2017, the first 250 patients undergoing NAVIO RA-TKA were included in this study. All intra-operative complications were recorded, including: bleeding; neuro-vascular injury; peri-articular soft tissue injury; extensor mechanism complications; and intra-operative fracture. During the first 90 days following surgery, patients were monitored for any post-operative complications, including: superficial and deep surgical site infection; pin-tract infection; pin site fractures; peri-prosthetic fractures; axial or sagittal joint instability; axial mal-alignment; patello-femoral instability; DVT/PE; re-operation or re-admission due to surgical-related complications. Surgical technique and multi-modality pain management protocol was consistent for all patients in the study. A combined anesthetic technique was employed for all cases, including: low-dose spinal, adductor canal block and general anesthetic. Patients were mobilized per our institution's rapid recovery protocol. Results. No patients were lost to follow-up. During the study period, no intra-operative complications were recorded. Specifically, no complications related to the introduction of the high-speed burr associated with the NAVIO RA-TKA were noted. Within the 90-day follow-up period, there was one case of deep infection. One patient sustained a fall resulting in a peri-prosthetic femoral fracture, that occurred remote from the femoral pin tracts. No cases of axial or sagittal joint instability, axial mal-alignment, patello-femoral instability, pin site infections or fractures; or DVT/PE were identified. Four patients underwent manipulation under anesthesia. No other patients required a re-operation or re-admission due to surgical-related complications. Discussion/Conclusions. The initial experience with the NAVIO robotic assisted total knee arthroplasty has demonstrated excellent safety profile. Relative to known risks associated with total knee arthroplasty, no increased risk of peri-operative complications, re-operation or re-admission for surgical related complications was identified with the introduction of the NAVIO RA-TKA

Increasing pressure to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA) is evident in current health care systems for numerous reasons. Patient autonomy and health care economics has challenged the ability of THA implants to maintain functional integrity before achieving bony union. Although collared stems have been shown to provide improved axial stability, it is unclear if this stability correlates with activity levels or results in improved early function to patients compared to collarless stems. This study aims to examine the role of implant design on patient activity and implant fixation. The early follow-up period was examined as the majority of variation between implants is expected during this time-frame. Patients (n=100) with unilateral hip OA who were undergoing primary THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=50) or collarless (n=50) cementless femoral stem. Patients will be seen at nine appointments (pre-operative, < 2 4 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Patients also underwent supine radiostereometric analysis (RSA) imaging < 2 4 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Nineteen collared stem patients and 20 collarless stem patients have been assessed. There were no demographic differences between groups. From < 2 4 hours to two weeks the collared implant subsided 0.90 ± 1.20 mm and the collarless implant subsided 3.32 ± 3.10 mm (p=0.014). From two weeks to three months the collared implant subsided 0.65 ± 1.54 mm and the collarless implant subsided 0.45 ± 0.52 mm (p=0.673). Subsidence following two weeks was lower than prior to two weeks in the collarless group (p=0.02) but not different in the collared group. Step count was reduced at two weeks compared to pre-operatively by 4078 ± 2959 steps for collared patients and 4282 ± 3187 steps for collarless patients (p=0.872). Step count increased from two weeks to three months by 6652 ± 4822 steps for collared patients and 4557 ± 2636 steps for collarless patients (p=0.289). TUG test time was increased at two weeks compared to pre-operatively by 4.71 ± 5.13 s for collared patients and 6.54 ± 10.18 s for collarless patients (p=0.551). TUG test time decreased from two weeks to three months by 7.21 ± 5.56 s for collared patients and 8.38 ± 7.20 s for collarless patients (p=0.685). There was no correlation between subsidence and step count or TUG test time. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. The presence of a collar on the stem did not affect patient activity and function and these factors were not correlated to subsidence, suggesting that initial fixation is instead primarily related to implant design

Background. There is increasing impetus to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA). The direct anterior (DA) approach is a muscle sparing technique that is believed to support these new pathways. Implants designed for these approaches are available in both collared and collarless variations and understanding the impact each has is important for providing the best treatment to patients. Purpose/Aim of Study. This study aims to examine the role of implant design on implant fixation and patient recovery. Materials and Methods. Patients (n=50) with unilateral hip OA who were undergoing primary DA THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=25) or collarless (n=25) cementless, fully hydroxyapatite coated femoral stem. Patients were seen at nine appointments (pre-operative, <24 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients underwent supine radiostereometric analysis (RSA) imaging <24 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Patients also completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Findings/Results. Twenty-two patients that received a collared stem and 27 patients that received a collarless stem have been assessed. There were no demographic differences between groups. From <24 hours to two weeks the collared implants subsided 0.90 ± 1.20 mm and the collarless implants subsided 3.80 ± 3.37 mm (p=0.001). From two weeks to three months the collared implants subsided 0.67 ± 1.61 mm and the collarless implants subsided 0.45 ± 0.46 mm (p=0.377). Step count was reduced at two weeks to 3108 ± 1388 steps for collared patients and 2340 ± 1685 steps for collarless patients (p=0.072). Step count was increased at three months to 8939 ± 3494 steps for collared patients and 6114 ± 2529 steps for collarless patients (p=0.034). TUG test time was increased at two weeks compared to pre-operatively by 3.45 ± 6.01 s for collared patients and 2.29 ± 4.92 s for collarless patients (p=0.754). TUG test time decreased from two weeks to three months by 6.30 ± 6.05 s for collared patients and 5.68 ± 4.68 s for collarless patients (p=0.922). Conclusions. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. Presence of a collar on the stem impacted patient activity but not function. This suggests that both the implant design as well as the surgical technique may play a role in the patient's early post-operative experience

CURRENT INDICATIONS. The ideal patient for unicompartmental arthroplasty has been described as an elderly sedentary individual with significant joint space loss isolated to either the medial or lateral compartment. Angular deformity should be no more than 5 or 10 degrees off a neutral mechanical axis. Ideal weight is below 180 pounds. Pre-operative flexion contracture should be less than 15 degrees. At surgery, the anterior cruciate ligament is ideally intact and there is no evidence of inflammatory synovitis. (Kozinn, Scott, 1989) Indications for the procedure have broadened today because of the availability of less invasive operative techniques and more rapid recovery with UKA. Because of its conservative nature, the procedure is being thought of as a conservative first arthroplasty in the middle-aged patient. Because of its less invasive nature with more rapid recovery and potentially less medical morbidity, it is being considered as the “last arthroplasty” in the octogenarian or older. OUTCOMES OF UKA. Initial results reported for UKA in the 1970s were not as encouraging as they are today. This is most likely due to lessons that had yet to be learned about patient selection, surgical technique and prosthetic design. By the 1980s, reported results were improving with post-operative range of motion much higher than that reported for TKA. As longer follow-ups were reported, results were obtained that were competitive with those reported for TKA. Through the first post-operative decade, revision rates were being seen at approximately 1% failure per year or a 90% survivorship of the prosthesis at 10 years. More recently, however, some 10-year results have been reported that have survivorship well over 95% at 10 years. Modes of failure most often consist of problems with component wear or loosening or due to secondary degeneration of the opposite compartment. This latter complication is usually a late cause of failure, but can occur early if the alignment of the knee is over-corrected by the surgical technique. UKA AS AN OPTION IN THE MIDDLE-AGED PATIENT. Although the classic selection criteria for UKA have emphasised the elderly patient as a candidate, the indications for UKA have been extended to a younger age group. The advantages of UKA in the middle-aged patient (especially female) are its higher initial success, few early complications, preservation of both cruciate ligaments and easier future conversion. Caution should be used, however, in advocating this procedure for the young, heavy, athletic person, as high levels of physical activity may be detrimental to the longevity of the procedure. LATERAL UKA. Lateral UKA is performed much less often than medial UKA (approximately 10% of UKAs are lateral). It is technically more challenging than medial arthroplasty. Some surgeons perform the procedure through a small lateral arthrotomy while others advocate a medial approach with care to avoid injury to the medial meniscus. This medial approach still yields excellent results with a short recovery while allowing the surgeon wide exposure to assess the joint, accurately perform the procedure and intra-operatively convert to a total knee arthroplasty if indicated. THE FUTURE. Research must continue in the areas of ideal patient selection, prosthetic design and surgical technique. Improvements in the durability of the polyethylene will enhance longevity. Mobile bearing articulations may improve long-term polyethylene wear by providing increased surface conformity without constraint

Economic data, clinical outcome studies, and anatomical studies continue to support the Superior Hip Approach as a preferred approach for improved safety, maximal tissue preservation, rapid recovery, and minimised cost. Clinical studies show exceedingly low rates of all major complications including femur fracture, dislocation, and nerve injury. Economic data from Q1 2013 to Q2 2016 demonstrate that CMS-insured patients treated by the Superior Hip Approach have the lowest cost of all patients treated in Massachusetts by an average of more than $7,000 over 90 days. The data show that the patients treated by the Superior Hip Approach have lower cost than any other surgical technique. Matched-pair bioskills dissections demonstrate far better preservation of the hip joint capsule and short external rotators than the anterior approach. Design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ prior to femoral neck osteotomy; Excision of the femoral head, thereby avoiding surgical dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intra-operative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Conclusion. In contrast to the results of the Superior Approach, the anterior approach continues to show difficulties with wound problems, infection, intra- and post-operative fracture, and failure of femoral component osseointegration and even dislocation. Evidence continues to demonstrate that the Superior Hip Approach has advantages over all other surgical approaches to the hip

The position of this surgeon is that there is no approach that provides superior outcomes for total hip replacement (THR). The direct anterior approach (DAA) has become popular with patients because of marketing by companies, misinformation given to journalists for public consumption, and yes, some surgeons. Because of patient pressure generated by this marketing there has been pressure on surgeons to convert their surgical approach for perceived protection of their practice. Unfortunately, the leaders of orthopaedic organizations have not countered this marketing with education of the public that there is NO scientific evidence to support DAA superiority. These orthopaedic organizations exist to be advocates for their members but have abdicated that responsibility. Whatever happened to the time honored belief of choosing a surgeon to do your operation? Instead we now choose an approach? Do anterior surgeons think that they are immune to the Bell Curve of talent? The fact is that there is NO outcome data of DAA with the longest follow up study being one year, and recent data from both coasts of the USA raise concerns with more failures from loosening of the femoral component. How in the world can we bamboozle patients about better results when there are no published results with the DAA except for recovery? The mini-posterior approach has data for all aspects of its use. Short term data shows rapid recovery and hospital discharge can be the same day; gait studies show A quality at six weeks (so does this mean that cut muscles recover quickly?). Dislocation rates are equal in most comparative studies, but I believe this favors the DAA, however, fractures are 3X greater with DAA. Data from the Mayo Clinic comparative studies showed posterior patients return to work faster! There are two 10 year studies of mini-posterior patients which show some of the best 10 year results in the literature. And there are superior technical surgeons who perform this operation to the benefit of their patients, and they should not need to suffer the implicit bias from DAA marketing that their care of patients is inferior

Total hip arthroplasty (THA) is reliable and reproducible in relieving pain and improving function in patients with end-stage arthritis of the hip joint. With improvements in surgical technique and advances in implant and instrument design, there has been a shift in focus from the technical aspects of the surgical procedure to improving the overall patient experience. In addition, shifts in medico-economic trends placed a premium on early patient mobilization, early discharge, and maximizing patient satisfaction. Arguably, a single most important advance in arthroplasty over the past 2 decades has been the development of multimodal pain protocols that form the foundation of many of the rapid recovery protocols today. The principal concept of multimodal analgesia is pain reduction through the utilization of multiple agents that synergistically act at various nodes of the pain pathway, thus, minimizing patient exposure to each individual agent and opioids in order to prevent opioid related adverse events (ORAE). Regional anesthesia has been shown to reduce post-operative pain, morphine consumption, and nausea and vomiting compared to general anesthesia but not length of stay. Additionally, general anesthesia has been shown to be associated with increased rates of post-operative adverse events, The use of peripheral nerve blocks in the form of sciatic, femoral or fascia iliaca blocks have not been shown to significantly reduce post-operative pain compared to controls. Periarticular infiltration of local anesthetics has been shown in some settings to reduce pain during the immediate post-operative period (<24 h). However, no significant differences were noted in terms of early recovery or complications. The use of liposomal bupivacaine (LB) local infiltration decreased pain and shortened length of stay comparable to patients receiving a fascia iliaca compartment block, and has been shown in relatively few randomised trials to provide improved pain relief at 24 hours only compared to conventional bupivacaine. Continuous intra-articular infusion of bupivacaine after THA did not significantly further reduce post-operative pain compared to placebo. In summary, the use of regional anesthesia when appropriate along with local anesthetic infiltration in the setting of a robust multimodal pain protocol minimises pain and complications while maximizing patient satisfaction following THA

The entirety of the patient experience after contemporary total knee and total hip replacements in 2017 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some include gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

Goals for total hip arthroplasty include acceleration of recovery, optimisation of component placement, minimisation of peri-operative complications, and maximal preservation of surrounding soft tissues. Achieving these goals when combined with appropriate implant design and manufacture can lead to decades of excellent hip function. With the exception of relatively rapid recovery, which can also be achieved with virtually all modern surgical exposures, the anterior hip approach fails to reliably achieve these goals. Problems with the anterior exposure for total hip arthroplasty are becoming increasingly recognised. Complications with equal or higher incidences than alternative exposures include: 1.) Early wound complications, 2.) Infection, 3.) Intra-operative and post-operative femur fracture, 4.) Greater trochanteric fracture, 5.) Dislocation, 6.) Femoral component loosening, 7.) Poor component placement, 8.) Poor soft tissue balance, 9.) Incisions with poor aesthetics and associated superficial hypaesthesia and dysaesthesia. These complications may be in part due to: 1.) The anterior and posterior soft tissue releases often necessary to complete the exposure, 2.) Poor ability to anatomically repair the hip joint capsule, 3.) Reduced choices of femoral components with restriction generally to those with less robust fixation, 4.) The poorly extensile nature of the interval, 5.) The need to place the incision in the region of the flexion crease, 6.) The limited ability to assess soft tissue balance and impingement-free range of motion at the time of surgery, 7.) The undue reliance on unvalidated, inaccurate imaging techniques to assess component placement. While experienced surgeons can achieve excellent results with the anterior (or virtually any other) exposure for total hip arthroplasty, the anterior exposure is by no means close to being a first among equals

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

Total hip arthroplasty (THA) represents one of the most safe and effective medical procedures. However, with an unchanged rate of 3% in primary and 10% in revision THAs, despite alleged surgical technique and implant design improvements, dislocation continues to be a matter of concerns with important functional and financial consequences. A number of parameters influence the risk for dislocation including patient specific factors, surgeon experience, femoral head size, implant orientation, and surgical approach. The latter has been less investigated during the past 15 years, as it was supposed that large femoral heads or specifically designed implants such as dual mobility sockets would notably decrease the risk for dislocation. Also, minimally invasive approach including the anterior approach, and rapid recovery have been aggressively marketed, making the transtrochanteric approach rarely if ever used by most surgeons. Also, this surgical technique is demanding and time consuming, not exactly what is expected in the 21st century. However, there are some clear advantages to the transtrochanteric approach both in primary and revision THAs: it gives a large view on the acetabulum allowing for anatomic reconstruction of the artificial joint and correct implants orientation; it allows for preservation of the entire periarticular muscles and tendons including the external rotators (external obturator+++); and it permits to balance the abductors tension by lowering and/or translating the greater trochanter. These advantages can notably reduce the rate of dislocation in both primary and revision THAs. Data from our institution including senior and junior surgeons have showed rates of dislocation ranging from 0.1 to 1.7% in primary THAs and from 1.5 to 2.3% in revision THAs. Our rate of nonunion is less than 2% even in revision using a specifically designed trochanteric claw plate almost systematically used in revision THAs to allow for a more rigid fixation. Finally, the transtrochanteric approach can be extended to the femur to cope with specific situations. The surgical tips and tricks of this approach will be discussed in the presentation