Elective Primary Total Hip Research Articles

Advocacy for use of the modified Iowa Level of Assistance Scale for clinical use in patients after hip replacement: an observational study

ObjectivesTo test the internal consistency and item difficulty of the modified Iowa Level of Assistance Scale (mILAS). DesignRetrospective observational study. SettingTwo orthopaedic wards of two general hospitals. ParticipantsFollowing elective primary unilateral total hip replacement surgery, all participants performed mILAS activities that were scored daily to assess their recovery of activities during hospitalisation. Main outcome measuresThe internal consistency and the level of assistance needed by the patient (item difficulty) of the mILAS were calculated using data from Deventer Hospital, Deventer, the Netherlands (n=255). A cross-validation was performed using data from Nij Smellinghe Hospital, Drachten, the Netherlands (n=224). ResultsThe internal consistency of the mILAS was acceptable on all three postoperative days (α=0.84 to 0.97). Cronbach’s α and Rasch analysis revealed a misfit of stair climbing with the other items of the mILAS. The item difficulty of the mILAS items changed over the first two postoperative days. During the first three postoperative days, the sit to supine transfer was generally the most difficult item to achieve, and the sit to stand transfer was the least difficult item to achieve as rated by physiotherapists. The cross-validation analysis revealed similar results. ConclusionsThe mILAS is a clinically sound measurement tool to assess the ability of patients to perform five functional tasks safely during hospitalisation. Stair climbing appears to be the easiest item to complete, and the sit to supine transfer is generally the most difficult after surgery.

Cost and determinants of acute kidney injury after elective primary total joint arthroplasty

BackgroundAcute kidney injury (AKI) is a serious complication after major surgery, which may lead to increased morbidity and mortality. The aim of this study was to identify cost and determinants of AKI after total joint arthroplasty.MethodsA retrospective case-controlled study was conducted with 1719 primary elective total hip or knee replacements performed from January 2004 through September 2015 at an urban teaching hospital. Patients who developed AKI were matched in a 1:3 ratio with those in a control group who did not develop AKI based on age, sex, race, operated joint, and comorbidities including hypertension and diabetes. Increased postoperative serum creatinine was considered indicative of AKI.ResultsFifty-four patients (3.1%) had AKI that was significantly associated with increased length of hospital stay (8.07 days) compared with that of the control group (4.50 days, P < .0001) and incurred significantly higher hospital charges ($224,533) than those of the control group ($142,753, P < .0001). We identified high body mass index, undergoing bilateral surgery in one session, high estimated blood loss, and longer duration of surgery as significant risk factors for AKI in univariate analysis. Elevated preoperative creatinine, large postoperative drop in hemoglobin, and high American Society of Anesthesiologists physical status scores were significant independent predictors of AKI in multivariate analysis.ConclusionsHealth-care providers and patients should work together to manage risk factors and to lower the risk of morbidity and mortality, longer in-hospital stay, and high associated costs of AKI.

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study

BackgroundA structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.MethodsApplying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.ResultsThirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.ConclusionThe consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Factors affecting the length of stay after total hip replacement; a retrospective analysis

Background: Total hip replacement is one of the most commonly performed surgical procedures. Healthcare budgets are finite. Much of the cost of total hip arthroplasty comprises the length of stay in hospital. Advancing care in joint replacement requires identification and correction of the factors affecting LOS. Materials & Methods: A retrospective case series of 299 patients of elective primary total hip replacement, performed between 04/2015 to 03/2016 in a District General Hospital to determine patient and implant related factors. Results: We looked at 299 patients. There was a clear correlation between ASA PS score and length of stay. With ASA PS Score one, LOS is three days, to ASA PS 3 = LOS five days. Effect of BMI on LOS is only significant in people with Grade III Obesity with average LOS is more than five days. Effect of age is only significant in patients above 80 years old. Patient with age range of 32 to 79 had an average LOS Four days but patient in the age group of above 80 years had an average LOS of Six days. Gender has an association with LOS in males four days and females have average LOS five days. Type of Implant shows an effect on LOS with shortest LOS four days in Uncemented Implants. Conclusions: Our study showed that LOS after THR is multi factorial. Health system resources are limited, understanding of these variables is important for more effective use of resource, safe practice and high patient satisfaction in delivery of Orthopaedic care.

Dialysis Dependence Predicts Complications, Intensive Care Unit Care, Length of Stay, and Skilled Nursing Needs in Elective Primary Total Knee and Hip Arthroplasty

BackgroundLimited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients. MethodsRetrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non–dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences. ResultsSix hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P < .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P < .001), discharge to facility (RR = 1.3, P < .001), and longer admission (1.5×, P < .001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P < .001), ICU care (RR = 6.0, P < .001), stroke (RR = 7.6, P < .001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P < .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P < .001). ConclusionDialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models.

Natural progress of D-dimer following total joint arthroplasty: a baseline for the diagnosis of the early postoperative infection

BackgroundEarly detection followed by prompt intervention is essential for the treatment of periprosthetic joint infection (PJI). D-dimer, a fibrin degradation product, characteristically changes rapidly during early postoperative period and has a short half-life. The aim of this prospective study was to measure postoperative change of D-dimer level after joint arthroplasty in conjunction with ESR and CRP.MethodsESR, CRP, and D-dimer levels were measured on the day before surgery, postoperative days 1, 2, 3, and 5 and weeks 2 and 6 in 65 patients who underwent elective primary total hip arthroplasty (38 hips in 38 patients) or total knee arthroplasty (27 knees in 27 patients). We compared perioperative changes of the three biomarkers.ResultsESR level was elevated from postoperative day 1 and reached a peak level of 45 mm/h at postoperative day 5. The elevation persisted until postoperative week 6. CRP level was elevated from postoperative day 1 and reached a peak level of 10 mg/dl between postoperative day 2 and day 3. The CRP level was decreased to the normal level around postoperative week 2. D-dimer level was sharply elevated and peaked to 4.5 μg/dl at postoperative day 1. At postoperative day 2, it decreased to baseline level. After then, it slowly elevated again and reached a second peak at postoperative week 2.ConclusionD-dimer showed a more rapid rise and fall than ESR and CRP in very early postoperative period. The D-dimer test might be effective in early detection of PJI, if combined with levels of ESR and CRP. The postoperative change of D-dimer in our study can serve as a baseline for early diagnosis of PJI.

Risk Factors for Early Dislocation Following Primary Elective Total Hip Arthroplasty

BackgroundDislocation following total hip arthroplasty (THA) continues to be one of the most common reasons for revision THA. The purpose of this study is to measure the current rate of dislocation following THA in the United States. A secondary goal is to identify patients at highest risk of instability after THA. MethodsThe Nationwide Readmissions Database was used to identify cases of elective primary THA between 2012 and 2014. All readmissions associated with dislocations were identified. Kaplan-Meier curves were used to assess the time to dislocation in the study population. A multivariate logistic regression was modeled to assess risk factors associated with readmission for dislocation. ResultsA total of 207,285 THAs were identified between 2012 and 2014. Of the total, 2842 dislocation-associated readmissions (1.4%) were identified, at a median of 40 days post-THA. A history of spinal fusion was the strongest independent predictor of dislocation (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.97-3.04; P < .0001). Parkinson's disease was also significantly associated with dislocation (OR, 1.63; 95% CI, 1.05-2.51; P = .03), as well as dementia (OR, 1.96; 95% CI, 1.13-3.39; P = .02), depression (OR, 1.28; 95% CI, 1.13-1.43; P < .0001), and chronic lung disease (OR, 1.2; 95% CI, 1.07-1.33; P = .001). Inflammatory arthritis and avascular necrosis were independent risk factors for dislocation (OR, 1.56; 95% CI, 1.25-1.97; P < .0001; OR, 1.67; 95% CI, 1.45-1.93; P < .0001). ConclusionTHA is a highly effective procedure with a low overall rate of instability. A history of spinal fusion was the most significant independent risk factor for dislocation within the first 6 months following THA.

Comparing outcomes between enhanced recovery after surgery and traditional protocols in total hip arthroplasty: a retrospective cohort study

Background: Traditionally, hip replacement surgery was associated with prolonged recovery and rehabilitation in a hospital setting. Prolonged stay is causing growing concern internationally, where there is an increased drive to cost-effective practice and a realisation that prolonged hospitalisation is not required and may be detrimental. Enhanced Recovery After Surgery (ERAS) protocols address this problem by advocating evidence-based multidisciplinary peri-operative management pathways associated with rapid recovery, without compromising safety. Despite proven efficacy, these protocols are not being implemented in most South African orthopaedic practices.Methods: Data from two cohorts (80 patients) undergoing elective primary total hip arthroplasty were included. One group was rehabilitated according to a prolonged stay protocol and the other according to ERAS. Cohorts were matched according to demographics and comorbidities. The functional outcome was compared using the Oxford Hip Score. The 30-day readmission rate was compared to assess the safety of early discharge, and the length of stay of patients was compared. Results: The readmission rate and Oxford Hip Scores showed no clinically significant difference between the cohorts. The length of stay was markedly decreased in the ERAS group. Conclusion: ERAS protocols can decrease the length of stay in elective total hip replacement without compromising patient safety or functional outcome.Level of evidence: Level 4

The Association of Delirium with Perioperative Complications in Primary Elective Total Hip Arthroplasty.

BackgroundOur goal was to determine whether postoperative delirium is associated with inpatient complication rates after primary elective total hip arthroplasty (THA).MethodsUsing the National Inpatient Sample, we analyzed records of patients who underwent primary elective THA from 2000 through 2009 to identify patients with delirium (n = 13,551) and without delirium (n = 1,992,971) and to assess major perioperative complications (acute renal failure, death, myocardial infarction, pneumonia, pulmonary embolism, and stroke) and minor perioperative complications (deep vein thrombosis, dislocation, general procedural complication, hematoma, seroma, and wound infection). Patient age, sex, length of hospital stay, and number of comorbidities were assessed. We used multivariate logistic regression to determine the association of delirium with complication rates (significance, p < 0.01).ResultsPatients with delirium were older (mean, 75 ± 0.2 vs. 65 ± 0.1 years), were more likely to be male (56% vs. 52%), had longer hospital stays (mean, 5.7 ± 0.07 vs. 3.8 ± 0.02 days), and had more comorbidities (mean, 2.8 ± 0.03 vs. 1.4 ± 0.01) (all p < 0.001) versus patients without delirium. Patients with delirium were more likely to have major (11% vs. 3%) and minor (17% vs. 7%) perioperative complications versus patients without delirium (both p < 0.001). When controlling for age, sex, and number of comorbidities, delirium was independently associated with major and minor complications (odds ratio, 2.0; 95% confidence interval, 1.7 to 2.3).ConclusionsDelirium is an independent risk factor for major and minor perioperative complications after primary elective THA.

Introduction of ‘Enhanced Recovery’ to patients undergoing elective total hip and knee replacement surgery

Purpose: The 2009–2012 Department of Health ‘Enhanced Recovery Partnership Programme’ documents that enhanced recovery (ER) of those patients undergoing elective primary total hip replacement (THR) and primary total knee replacement (TKR) surgery should include pre-operative assessment/education; and early mobilisation in the post-operative period (Simpson et al., 2015).

Racial Disparity in the Perioperative Care for Patients Undergoing Total Knee and Hip Arthroplasty: A Retrospective Propensity-Matched Cohort Study.

Total joint arthroplasty is an effective treatment for osteoarthritis-related symptoms not resolved with non-surgical therapy. There is a growing body of evidence supporting the use of neuraxial anesthesia for these surgical procedures. We utilized the American College of Surgeons-National Surgical Quality Improvement Program database to study the effects of race on the type of anesthesia and postoperative outcomes in elective total joint replacement surgery. We included African-American and White adult patients (age>18years) undergoing elective primary total knee or hip arthroplasty under general or neuraxial (spinal or epidural) anesthesia (2005-2013). A 1:3 matched sample of African-American vs. White patients was created based on propensity scores. The differences in anesthetic technique and postoperative complications between the two groups were evaluated before and after matching. A total of 102,122 patients were included. African-American patients were younger (mean±standard deviation, 62.08±11.17 vs. 66.37±10.53years, p<0.001) and had a lower modified Charlson comorbidity index (CCI) score (3.07±1.39 vs. 3.42±1.33, p<0.001). General anesthesia was used more commonly in the African-American patients group (64.56 vs. 62.25%, p<0.001). However, when the two groups were matched, the differences in the type of anesthesia disappeared (odds ratio [OR] 0.96, 95% confidence limits [CL] 0.85-1.08, p=0.455). African-American patients had a higher rate of 30-day postoperative complications before matching (3.08 vs. 2.20%, p<0.001) and after matching (3.63 vs. 2.33%) (OR 1.58, 95% CL 1.13-2.21, p=0.007). There is no significant difference in the type of anesthesia received for total joint arthroplasty between African-American and White patients; however, there is a disparity in the postoperative outcomes in favor of the White patient group. Further studies needed to explain the reasons for these findings.

Predicting Perioperative Transfusion in Elective Hip and Knee Arthroplasty: A Validated Predictive Model.

Preoperative anemia is a significant predictor of perioperative erythrocyte transfusion in elective arthroplasty patients. However, interactions with other patient and procedure characteristics predicting transfusion requirements have not been well studied. Patients undergoing elective primary total hip arthroplasty or total knee arthroplasty at a tertiary hospital in Adelaide, South Australia, Australia, from January 2010 to June 2014 were used to identify preoperative predictors of perioperative transfusion. A logistic regression model was developed and externally validated with an independent data set from three other hospitals in Adelaide. Altogether, 737 adult patients in the derivation group and 653 patients in the validation group were included. Binary logistic regression modeling identified preoperative hemoglobin (odds ratio, 0.51; 95% CI, 0.43 to 0.59; P < 0.001 for each 1 g/dl increase), total hip arthroplasty (odds ratio, 3.56; 95% CI, 2.39 to 5.30; P < 0.001), and females 65 yr of age and older (odds ratio, 3.37; 95% CI, 1.88 to 6.04; P = 0.01) as predictors of transfusion in the derivation cohort. Using a combination of patient-specific preoperative variables, this validated model can predict transfusion in patients undergoing elective hip and knee arthroplasty. The model may also help to identify patients whose need for transfusion may be decreased through preoperative hemoglobin optimization.

Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty.

In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty. Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01. Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges. Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Manual calf massage and passive ankle motion reduce the incidence of deep vein thromboembolism after total hip arthroplasty.

Venous thromboembolism is one of the general complications following total hip arthroplasty, wherein various preventive treatments have been recommended. Several studies reported that venous thromboembolism incidence after total hip arthroplasty was similar in patients who were administered prophylaxis with a conventional mechanical procedure alone, and those who were administered pharmacological anticoagulation therapy. Therefore, the optimum methods of prophylaxis are still controversial. The purpose of this study was to investigate whether manual calf massage and passive ankle motion could lower the risk for venous thromboembolism after total hip arthroplasty. We retrospectively reviewed the data of 126 consecutive patients undergoing elective primary unilateral total hip arthroplasty wherein manual calf massage and passive ankle motion were performed after the surgery at our hospitals between January and October 2014. The 138 patients of the control group underwent total hip arthroplasty using the same surgical approach and pre- and postoperative protocols without this mechanical prophylaxis between January and December 2013. This mechanical prophylaxis was performed simultaneously 30 times during approximately 10s; these procedures were repeated thrice immediately after total hip arthroplasty. Duplex ultrasonography was performed to observe the veins of both legs in all the patients on postoperative day 7. The incidence of deep vein thrombosis was 6.52% and 0.79% in the control and manual calf massage and passive ankle motion groups, respectively. The odds ratio for the manual calf massage and passive ankle motion groups was 8.72. Performing this mechanical prophylaxis reduced the incidence of venous thromboembolism after total hip arthroplasty. This mechanical prophylaxis is not only simple and easy, but is also safe and inexpensive. We therefore recommend that manual calf massage and passive ankle motion be performed in patients who will undergo total hip arthroplasty, if deep vein thrombosis does not exist before the surgery.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BackgroundAlthough resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. MethodsWe identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. ResultsPatients undergoing surgery at teaching hospitals had longer lengths of stay (β = 3.2%; P < .001) and higher costs of admission (β = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). ConclusionPrimary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines

BackgroundFollowing evidence questioning the safety and efficacy of perioperative beta-blocker therapy in noncardiac surgery, the Surgical Care Improvement Project (SCIP) guidelines were retired in 2015. However, perioperative myocardial infarctions and cardiac complications remain leading causes of mortality following noncardiac surgery. The impact of the SCIP guidelines on reducing cardiac complications in patients undergoing elective total hip arthroplasty (THA) has not been evaluated. MethodsThe Nationwide Inpatient Sample was queried for 345,875 elective THA performed from 2003 to 2011. Patient demographics and morbidity as well as the incidence of nonfatal and fatal cardiac complications and overall mortality associated with cardiac complications were determined before and following SCIP implementation. ResultsFollowing the institution of the SCIP guidelines, the overall mortality following cardiac complications decreased by 41%. Although the incidence of nonfatal cardiac events after THA did increase 5% (primarily secondary to an increased incidence of nonfatal hypotension), the incidence of postoperative inpatient mortality, stroke, fatal hypotension, fatal myocardial infarction, and nonfatal and fatal cardiac arrest significantly decreased. ConclusionFollowing the implementation of SCIP guidelines, there was a 41% reduction in mortality and a significant decrease in fatal cardiac complications, postoperative hypotension, myocardial infarction, and cardiac arrest. Despite SCIP guidelines being retired in 2015, evidence supports continuation of perioperative beta-blockade in primary elective total adult hip and knee arthroplasty.

Lower Urinary Tract Infection and Periprosthetic Joint Infection after Elective Primary Total Hip Arthroplasty.

PurposePeriprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a grave complication. Urinary tract infection (UTI) as a source for PJI is controversial. Our purposes were, (1) to evaluate the incidence of PJI after elective primary THA and (2) to determine whether UTI was associated with a risk of PJI after elective primary THA.Materials and MethodsWe retrospectively reviewed the medical records of 527 patients who underwent elective primary THA by using universal aseptic technique from May 2003 to October 2007. UTI group (13 patients) was defined as patients who underwent THA in status of having an UTI, and the remaining patients were defined as control group (514 patients). We compared the incidence of PJI in both groups.ResultsDuring the study period, the incidence of PJI was 0%, regardless of existence (or presence) of UTI.ConclusionThere was no significant association between UTI and PJI, when cautiously performed THA.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital

BackgroundTotal joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model. MethodsUsing a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013. ResultsIn total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period. ConclusionIncreasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Late Complications Following Elective Primary Total Hip and Knee Arthroplasty: Who, When, and How?

BackgroundImproved pain management and early mobilization protocols have increased interest in the feasibility of short stay (<24 hours) or outpatient total hip (THA) and total knee (TKA) arthroplasty. However, concerns exist regarding patient safety and readmissions. The purposes of this study were to determine the incidence of in-hospital complications following THA/TKA, to create a model to identify comorbidities associated with the risk of developing major complications >24 hours postoperatively, and to validate this model against another consecutive series of patients. MethodsWe prospectively evaluated a consecutive series of 802 patients who underwent elective primary THA and TKA over a 9-month period. The mean age was 62.3 years. Demographic, surgical, and postoperative readmission data were entered into an arthroplasty database. ResultsOf the 802 patients, 382 experienced a complication postoperatively. Of these, 152 (19%) required active management. Multiple logistic regression analysis identified cirrhosis (odds ratio [OR], 5.89; 95% confidence interval [CI], 1.05-33.07; P = .044), congestive heart failure (OR, 3.12; 95% CI, 1.50-6.44; P = .002), and chronic kidney disease (OR, 3.85; 95% CI, 2.21-6.71; P < .001) as risk factors for late complications. One comorbidity was associated with a 77% probability of developing a major postoperative complication. This model was validated against an independent dataset of 1012 patients. ConclusionWith improved pain management and mobilization protocols, there is increasing interest in short stay and outpatient THA and TKA. Patients with cirrhosis, congestive heart failure, or chronic kidney disease should be excluded from early discharge total joint arthroplasty protocols.

Inpatient mortality after elective primary total hip and knee joint arthroplasty in Botswana.

Total hip and knee joint arthroplasty (TJA) rank among the most successful orthopaedic operations. Several developing countries in Africa have started to perform these procedures that are routine in developed countries. The aims of this study were to measure the incidence and assess the determinants of in-hospital mortality after elective primary TJA in our unit and compare it with published data. This was a retrospective study of the first consecutive cohort of patients who underwent elective primary TJA in Princess Marina Hospital, Botswana between March 2009 and October 2015 (6.5 years). 346 elective joint replacements were performed comprising 153 total hip arthroplasties (THA) and 193 total knee arthroplasties (TKA); 36% of the THA were in female patients and 82% of TKA were in females. The mean age was 64.5years (range 26-86). Three patients died giving an inpatient mortality rate of 0.86%. These three mortalities represent 1.55% (three out of 193) of all the TKA. There were no deaths after THA. The cause of mortality in two patients was an adverse cardiac event while the third mortality was due to pulmonary embolism. The inpatient mortality rate of 0.86% following TJA is higher than the reported rates in the developed countries but comparable with data from other developing countries. The inpatient mortality rate following TKA was higher than that following THA and cardiovascular events proved to be the main cause of death. We recommend formal cardiology assessment and close peri-operative monitoring of all patients with a history of cardiovascular disease undergoing TJA.