Total joint arthroplasty (TJA) has historically been considered primarily an inpatient operation. However, the actual length of stay (LOS) has diminished over time. At our institution the LOS from 1987 to 1990 averaged five to seven days. This decreased to three days from 1993 to 2002 and down to one to two days from 2005 to 2011. With the adaptation of improved anesthesia and pain management protocols, minimally invasive surgery techniques, rapid recovery protocols, and proper patient selection, outpatient (OP) TJA appears to be the next step in maximizing peri-operative efficiency; especially as younger patients are undergoing TJA. Other potential benefits of OP TJR include improved patient care and control, better patient and surgeon satisfaction and a lower overall cost. Over a twenty-four month period (July 2012 to June 2014) we performed 250 primary TJAs (139 hips and 111 knees) and twelve revision TJAs (six hips and six knees). All patients received 400 mg of celecoxib pre-operation and 200 mg/day for ten days. In addition to general anesthesia, hips received a short-acting spinal and knees received an adductor canal block. Tranexamic acid (IV or topical) and a pericapsular injectable cocktail of liposomal bupivacaine was routinely used. There was one deep infection (0.4%) and one readmission for pain control (0.4%). Two cases of deep vein thrombosis were diagnosed (0.8%). Patient education, home health care utilization, and proper patient selection are key factors to keep hospitalization rates, emergency room visits, and re-admission rates to a minimum

Utilising the (ACS-NSQIP) database, we aimed to evaluate the impact of resident level of training on surgical outcome following (TKA) and to compare the US and Canadian health care training system in regards to 30 days postoperative complications and readmission rates. Using the (CPT) codes we selected from the 2011 and 2012 NSQIP database elective primary TKA with the resident surgeon involved. Of these, all cases with a primary diagnosis code of infection, fracture, mechanical complication, or malignancy and all cases with incomplete or incongruous demographic information were excluded. We also eliminated all the cases with the Attending not present. A total of 2513 cases were included in the study. The cases were stratified into three groups according to the postgraduate level of training {PGY 1 to 3 (junior resident), PGY 4 to 5 (senior resident), and fellow}. Univariate analysis of all patient demographics, comorbidities, intra and postoperative variables, length of surgery, hospital stay and 30 days readmission rates were conducted in order to identify differences between the groups. A standard student's t test was used for continuous variables while the ChiSquared was used for categorical variables. Multivariable logistic regression models were created to assess the independent effect of the resident level of training on the 30 days major complication and re-admission rates while controlling for all other variables. We identified, 854 (34%) TKAs with junior residents, 1013 (40%) TKAs with senior residents and 646 (26%) TKAs with fellows' participation. Junior residents had a significant (p<0.0001) longer operative time (107±36 minutes) compared with senior residents and fellows. Length of hospital stay was longer in the fellow group probably because of their involvement in more complicated cases. Additionally, an increased number of blood transfusion was observed for the cases performed with involvement of senior residents when compared with the other two groups. However, no significant difference in complications was observed across training levels. When comparing US (2074 TKAs) versus Canada (423 TKAs) cases, we found that fellow contribution to TKA surgeries is higher in Canada. The occurrence of pulmonary embolism and pneumonia was three times higher in Canada cases, while blood transfusion was more frequent in US. Increased operative time, ASA class, age, diabetes, percutaneous cardiac intervention, and steroid use were all independent risk factors for complications following primary TKA. However, no significant difference was observed between the two groups with regards to major complications suggesting no difference between Canadian and American training system in regards to post operative complication. Our results support previous study study indicating that involvement of residents did not affect the surgical outcome within 30 days when compared to cases with no resident involvement. Our study suggests that resident level does not independently increase the risk of short term complications and support continuing involvement of junior trainees in TKA

Introduction. Measured outcomes from knee joint arthroplasty (TKA) have primarily focused on surgeon-directed criteria, such as alignment, range of motion measured in the clinic, and implant durability, rather than on functional outcomes. There is strong evidence that subjective reporting by patients fails to capture objective real-life function. 1,2. We believe that the recent emphasis on clinical outcomes desired by the patient, as well as the need to demonstrate value, requires a new approach to patient outcomes that directly monitors ambulatory activity after surgery. We have developed and tested a system that: 1) autonomously identifies patients who are not progressing well in their recovery from TKA surgery; 2) characterizes patient activity profiles; 3) automatically alerts health care providers of patients who should be seen for additional follow-up. We anticipate that such a system could decrease secondary procedures such as manipulation under anesthesia (MUA) and reduce hospital re-admission rates thereby resulting in significant cost savings to the patient, the care providers, and insurers. Methods. The components of the system include: 1) A sensor package that is mounted correctly in relation to the knee joint (Figure 1a) and is suitable for long term use; 2) An application that runs under the Android operating system to communicate with the sensor and to gather subjective information (pain, satisfaction, perceived stability etc. together with a photograph of the surgical site (Figure 1b); 3) Software to upload the data from the phone to a remote server; 4) An analysis and reporting package that generates, among other metrics, a profile describing the patient's activity throughout the day, trends in the recovery process, and alerts for abnormal findings (Figure 1c). The system was pilot tested on 12 patients (7 females) who underwent TKA. Complete days of data collection were scheduled for each patient every two weeks until 12 weeks, starting during the second week after surgery. Results. Patients tolerated the system well and datasets of up to 13 hours long were recorded. There was a considerable variation between patients in the use of the prosthetic knee joint at a given time point after surgery. At 6 weeks post-surgery, for example, some relatively inactive subjects had less than 50 excursions per hour while active subjects exhibited more than 750 excursions per hour. It was notable that, in activities of daily living, subjects rarely used the extremes of the flexion range that had been measured during post-operative clinic visits. Examples of activity recognition during free-living will be presented. Discussion. A remote knee monitoring system has been designed and successfully tested in an outpatient setting. The system has revealed discrepancies between knee function measured during clinic visits and that measured remotely during free living. Remote monitoring after orthopaedic procedures adds an important new dimension to the assessment of patient outcome. Acknowledgments. This work was supported by grants from the Washington Research Foundation and The Wallace H. Coulter Translational Partnership at the University of Washington

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

Enhanced recovery pathways (ERPs) utilise multimodal rehabilitation techniques to reduce post-operative pain and accelerate the rehabilitation process following surgery. Originally described following elective colonic surgery enhanced recovery pathways have gained increasing use following elective hip and knee joint replacement in recent years. Early studies have indicated that enhanced recovery pathways can reduce length of hospital stay, reduce complications and improve cost-effectiveness of joint replacement surgery. Despite this growing evidence base uptake has been slow in certain centres and many surgeons are yet to utilise enhanced recovery pathways in their practice. We look at the process and effects of implementing an enhanced recovery pathway following total hip replacement surgery at a district general hospital in the United Kingdom. A retrospective study was initially undertaken over a four-month period to assess patient demographics, length of stay, time to physiotherapy and complication rates including re-admission within 28 days. Based on national recommendations an enhanced recovery pathway protocol was then implemented for an elective total hip replacement list. Inclusion criteria were elective patients undergoing primary total hip replacement (THR) surgery. The pathway included pre-operative nutrition optimisation, 4mg ondansetron, 8mg dexamethasone and 1g tranexamic acid at induction and 150mL ropivacaine HCL 0.2%, 30mg ketorolac and adrenaline (RKA) mix infiltration to joint capsule, external rotators, gluteus tendon, iliotibial band, soft-tissues and skin around the hip joint. The patient was mobilised four-hours after surgery where possible and aimed to be discharged once mobile and pain was under control. Following implementation a prospective study was undertaken to compare patient demographics, length of stay and complication rates including re-admission within 28 days. 34 patients met the inclusion criteria and were included in each group pre and post-enhanced recovery pathway. Following implementation of an enhanced recovery pathway mean length of stay decreased from 5.4 days to 3.5 days (CI 1.94, p < 0.0001). Sub-group analysis based on ASA grade revealed that this reduction in length of stay was most pronounced in ASA 1 patients with mean length of stay reduced from 5.0 days to 3.2 days (CI 1.83, p < 0.0001). There was no significant change in the number of complications or re-admission rates following enhanced recovery pathway. The enhanced recovery pathway was quick and easy to implement with co-ordination between surgeons, anaesthetist, nursing staff and patients. This observational study of consecutive primary total hip replacement patients shows a substantial reduction in length of stay with no change in complication rates after the introduction of a multimodal enhanced recovery protocol. Both of these factors reduce hospital costs for elective THR patients and may improve patient experiences

Purpose. The purpose of this study was to compare the outcomes and complications of normal weight, class one obese (BMI=30-34.9 kg/m2) and superobese (BMI≥50 kg/m2) primary total knee replacement (TKR) patients. Method. Between January 1995 and December 2005, 4104 primary TKR were performed in our centre. Patients were stratified for their obesity level according the World Health Organisation (WHO) and current surgical literature classification. Sixty-seven superobese patients (group one) were identified. They were matched with normal weight (group two) and class one obese (group three) primary TKR patients for sex, age, side, preoperative diagnosis, implants used, time since surgery and preoperative SF-12 mental component summary score (MCS). Patient clinical outcomes (WOMAC, SF-12 and Knee Society scores), radiographs, complications, readmissions, and revisions rates were compared for normal BMI, class one obese and superobese patients. Results. The mean BMI of our primary TKR patients was 32,6. Using the WHO BMI classification, 0.3% were underweight, 10.4% normal weight, 30.1 % overweight, 31.0 % class 1 obesity, 16.5 % class 2 obesity, 9.8 % class 3 obesity and 1.9 % superobese. Superobese population (n=67) was 61.59.2 yo, with sex ratio at 5.1 (F=56;M=11), preoperative SF-12 MCS at 52.610.6. Their preoperative diagnosis was osteoarthritis (n=62) or inflammatory arthritis (n=5). All groups were equal (n=67) and were similar for these characteristics. Mean clinical and radiographic follow-up was 7.33.2 yrs. Superobese patients presented lower preoperative SF-12 physical component summary (PCS; gp 1=26.05.6; gp 2=29.68.4; gp 3=30.57.8; p<0.05), Knee Society score (gp 1=73.626.4; gp 2=84.926.5; gp 3=88.517.4; p<0.05) and WOMAC scores (gp 1=35.814.5; gp 2=44.116.7; gp 3=41.315.7; p<0.05). However the three groups presented a similar improvement of the SF-12 PCS (gp1=10.512.0; gp2= 6.810.9; gp3=6.812.1; p= 0.22) and Knee Society score (gp1=81.930.8; gp 2= 74.220.9; gp 3=78.729.9; p= 0.21). The superobese patients group had a significantly longer hospital stay, higher complication rate, and were more frequently re-admitted to hospital and submitted to revision surgery. Conclusion. Superobese patients can enjoy comparable clinical outcomes when compared to patients with lower BMIs, but do run increased risks in terms of a complication and a greater hospital re-admission rate

The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the aspirin controversy is presumably resolved, there is no medical evidence for the “optimal” VTE prophylaxis regime for individual patients. A risk-stratified multi-modal VTE prophylaxis protocol was developed and adopted by consensus. VTE risk factors and bleeding risk factors were categorised into six VTE/bleeding risk levels: (1) pre-operative vitamin K antagonists (VKA) use, (2) bleeding risk factors, (3) hypercoagulable state, (4) pre-operative anti-platelet therapy [clopidogrel use], (5) VTE risk factors, (6) no VTE or bleeding risk factors. The pharmacologic agents used for each risk level were: (1) resume VKA with low molecular weight heparin (LMWH) bridge, (2) pharmacologic agents contra-indicated and mechanical prophylaxis only, (3) VKA for 90 days with LMWH bridge, (4) resume anti-platelet therapy, (5) LMWH in hospital and discharge on aspirin for 90 days, (6) aspirin for 90 days (starting in hospital). In addition to pharmacologic treatment, all patients received multi-modal prophylaxis including early mobilisation, mechanical foot pumps, and neuraxial anesthesia when not contra-indicated. Prior to surgery, a VTE/bleeding risk factor checklist was completed determining the risk level. The intervention cohort included all TJA patients from January 1, 2010 to December 31, 2012. The comparison cohort included all TJA patients from the year prior to implementation of the protocol at the same community hospital. Thirty day all-cause non-elective re-admissions, 30 day same-site re-operations, 90 day VTE events, and protocol compliance were abstracted from the electronic medical record. The intervention group consisted of 2679 patients (1075 hip arthroplasty patients and 1604 knee arthroplasty patients). The comparison group consisted of 1118 patients (323 hip arthroplasty patients and 795 knee arthroplasty patients). The 30 day all cause non-elective re-admission rate was 2.72% (73/2679) in the intervention group and 4.29% (48/1118) in the comparison group (p=0.0148). The 30 day same-site re-operation rate was 1.38% (37/2679) in the intervention group and 1.25% (14/1118) in the comparison group (p=0.8773). The 90 day VTE event rate was 1.57% (42/2679) in the intervention group and 3.40% (38/1118) in the comparison group (p=0.0007). The VTE rate was higher for knee arthroplasty patients 2.00% (32/1604) than for hip arthroplasty patients 0.93% (10/1075) (p=0.0379). The rate of VTE events was higher for patients that deviated from the VTE protocol 5.03% (10/199) than for all risk groups treated per the protocol 1.29% (32/2481) (p=0.0007). The risk-stratified multi-modal VTE prophylaxis protocol simultaneously reduced 30 day all-cause non-elective re-admissions and 90 day VTE events. The possible causes for reducing 30 day re-admissions and reducing 90 day VTE events are: (1) reducing bleeding events by using aspirin for VTE prophylaxis in more than 80% of patients, (2) extending VTE prophylaxis to 90 days, and (3) using multi-modal prophylaxis. The risk-stratified multi-modal VTE prophylaxis protocol for total joint arthroplasty is consistent with 9 of the 10 recommendations in the AAOS Clinical Practice Guideline. The risk-stratification checklist provides a standardised tool to assess risks, discuss risks, and make shared decision with patients. Patient treatment that deviated from the protocol had a significantly higher VTE rate (5.03%). Protocol compliance increased each year from 91.1% in 2010 to 94.2% in 2012

Aims

Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA.