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. 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).INTRODUCTION
METHODS
Liposomal bupivacaine has been shown to be effective in managing post-operative pain in hallux valgus and hemorrhoid surgery. However, non-industry-supported and well-powered randomized studies evaluating its efficacy in Total Knee Arthroplasty (TKA) are lacking. Our hypothesis was that liposomal bupivacaine would not decrease post-operative visual analog pain scores (VAS) or narcotic consumption in the acute post-operative period. Two hundred seven consecutive patients were enrolled into a single-blinded prospective randomized study. We included patients undergoing unilateral TKA by five fellowship-trained surgeons with a diagnosis of osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis. Patients were excluded for any other diagnosis necessitating TKA, allergy to the medications, or pre-operative opiate use. Participants received standardized pain management, anesthesia, and physical therapy. Patients were randomized intra-operatively to one of three groups: an intra-articular (IA) injection of bupivacaine and morphine at the conclusion of the procedure, a peri-articular (PA) injection of a bupivacaine and morphine, or a PA injection of liposomal bupivacaine. Post-operative pain VAS and mean morphine equivalents (MME) consumed were recorded and compared utilizing analysis of variance (ANOVA). A power analysis demonstrated that 159 patients were needed for 80% power to detect a 25% difference in VAS or MME.Introduction
Methodology
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. 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).Introduction
Methods
To determine the tensile forces across the knee extensor mechanism during walking, in simulated conditions of treatment. Gait analysis of six normal subjects was performed, with full weight bearing unilateral immobilisation of the knee during walking. Measurements were taken without then with a brace, unlocked then locked at 0°, 0-10°, 0-20° and 0-30° of flexion. Mean and maximum knee flexion angles were measured, followed by calculation of the mean and maximum forces across the extensor mechanism during loading, supporting and propulsion phases of gait.Aim
Methods
The aim of this study was two-fold; firstly, to investigate the construct validity of the Disability of the Arm, Shoulder and Hand (DASH) score in patients following injuries to the upper and lower limbs, and to confirm that DASH score does not measure disability solely attributed to the upper limb. Secondly, to create a modified DASH questionnaire (M2 DASH) with fewer questions that can discriminate clearly between disabilities due to problems at the upper limb, and is more specific to the upper limb. Patients were asked to fill in the DASH questionnaire in a fracture clinic following ethical approval. This included upper limb injuries (79), lower limb injuries (61) and control subjects (52). The median DASH scores for the three groups were 57, 16 and one respectively. The DASH scores varied significantly between the three groups (Kruskal-Wallis: p<
0.001); the scores for the upper limb group were higher than the lower limb group, and the scores for the lower limb group was higher than the control group (Mann-Whitney: p<
0.001). The M2 DASH questionnaire was developed using questions specific to the upper limb and included questions 1–4, 6, 13–17, 21–23 and 26–30. The median M2 DASH scores for the three groups were 50, 7 and 0 respectively. The revised questionnaire score was then calculated for the upper limb group and a correlation study showed good correlation between the two questionnaires. Our study shows that the original DASH questionnaire is not specific for the upper limb. This has important implications in measuring response in injuries and disease that involve both upper and lower limbs. We have devised a revised questionnaire that we suggest is referred to as M2 DASH questionnaire. The M2 DASH questionnaire has the advantage of being more specific for the upper limb than the DASH questionnaire.
We present one of the largest reported series of such fractures in which we have explored the above statements.
The patients were followed up in the outpatients clinic for a mean period of 2 months (group 1) and 16 months (group 2). The distance of the fracture site from the proximal tip of the metatarsal was measured on the radiographs.
All group 1 fractures healed well following symptomatic management and none required surgical intervention. Acute fractures in group 2 did better with non-weight bearing mobilization. Stress related fractures in group 2 took longer to heal when managed non-operatively. In group 2 patients, the difference in the site of acute &
stress fractures was not statistically significant. No statistically significant correlation between distance from the proximal tip of the fifth metatarsal to the fracture site and union.
A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. Nonunion in fractures distal to the tuberosity is not related to the distance of the fracture from the metaphyseal-diaphyseal region Acute and stress fractures distal to the tuberosity do not occur at different anatomic sites.
The effect of pre-operative pain, physical function, mental function and multiple patient factors on patient outcome following TKR was examined. After informed consent, 105 patients undergoing primary TKR completed preoperative SF-36 and WOMAC questionnaires and a Knee Society Score (KSS) was determined. These scores were repeated at 12 months. Patient data studied included age, gender, BMI and significant comorbid conditions such as diabetes, cardiac disease, and COPD. Statistical analysis included a univariate analysis, followed by a bivariate analysis and multiple regression analysis. All physical dimensions of the SF-36, WOMAC and KSS showed highly significant improvements after one year. The KSS improved to a mean of 94.8 (p<
0.000001). For patients greater than 65 years of age, postoperative physical function was returned to normative scores for age matched controls. For patients less than 65, physical function did not reach age matched controls even though similar improvements in physical function were seen. Patients with lower physical function scores (PCS) pre-operatively showed greater improvement postoperatively yet did not reach the same absolute level of function as patients who had higher preoperative physical function. The mean PCS for men increased from 35 to 42, while for women it increased from 29 to 42 (p=0.042). Preoperative mental function (MCS) was a strong predictor of postoperative physical function. Patients with low preoperative MCS and one or more comorbid conditions were 10.1 times more likely to have a poor outcome following TKR. Knowledge of preoperative physical function, mental function, gender, age and comorbid conditions improves prediction of post-operative physical function after TKR. Patients at high risk for little improvement following TKR are those with low preoperative mental function (MCS<
50) in addition to one or more comorbid conditions. These patients can be identified during the pre-operative period.
