Outpatient Total Hip Arthroplasty Research Articles

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review.

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Risk Factors of Failure to Discharge Before “Two Midnights” in Outpatient-Designated Total Hip Arthroplasty

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days. Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days. Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection (P < 0.01), hospital readmission (P < 0.01), and revision surgery (P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days. Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices

BackgroundDespite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. MethodsThis nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. ResultsOral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. ConclusionsPerioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained

BackgroundThis study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. MethodsA consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). ResultsThe mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. ConclusionsOur study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.

Multi-center experience with outpatient total hip arthroplasty via a standard posterolateral approach.

This study sought to evaluate the safety, efficacy, and resource utilization of a pilot outpatient surgery program for total hip arthroplasty compared to traditional inpatient total hip arthroplasty performed via the posterolateral approach. A cohort of 68 patients from two sites were enrolled in a regional pilot project for outpatient total hip arthroplasty (THA) and matched 1:1 against a cohort of patients undergoing routine inpatient THA. Data was extracted retrospectively from patient and hospital charts including adverse events (AE), readmission within 90 days, emergency room (ER) visits, patient calls, patient-reported outcome measures, length of stay, and multiple surgical variables. The outpatient group had a mean hospital stay of 13 hours, whereas the inpatient group had a mean of 58 hours (p<0.001). Three outpatients and four inpatients experienced post-op complications. Three inpatients and one outpatient visited the ER within 8 weeks of surgery. No difference in pre-operative hemoglobin (p = 0.210), or surgical blood loss (p = 0.550) was found between study groups. There was no difference found between groups regarding Oxford-12 Hip Score improvement, nor satisfaction at six months, one and two years (p>0.125). This study demonstrates that outpatient THA using the posterolateral approach is as safe and effective as inpatient THA for overall healthy and carefully screened patients, based on the low rate of AEs observed and similar patient outcomes reported. Significantly reduced time in hospital demonstrates the reduced healthcare resources associated with outpatient THA.

Site of Service Disparities Exist for Total Joint Arthroplasty.

The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

Outpatient Total Hip Arthroplasty Volume up Nearly 8-Fold After Regulatory Changes With Expanding Demographics and Unchanging Outcomes: A 10-Year Analysis

BackgroundWith the removal of total hip arthroplasty (THA) from the inpatient-only (IPO) lists, the orthopedic landscape across the United States has changed rapidly. Thus, this study aimed to: 1) characterize the change in THA volume for outpatient and inpatient surgeries; 2) elucidate demographical differences before and after removal from the IPO list; and 3) analyze 30-day complications, readmissions, and reoperations. MethodsThe National Surgical Quality Improvement Program database was queried for primary THAs between January 2010 and December 2021. The primary outcome was the annual volume of outpatient and inpatient THAs. Secondary outcomes involved 30-day complications, readmissions, and reoperations. The variables between cohorts were analyzed using goodness-of-fit Chi-square tests with summary statistics. ResultsOf the 332,423 THAs between 2010 and 2021, 88% were inpatient THAs (n = 292,974) and 12% were outpatient THAs (n = 39,449). From 2019 to 2021, the volume of inpatient THA decreased by 55% (42,779 to 19,075), while outpatient THA increased by 751% (2,518 to 21,424). Patients who had a THA after 2019 were older (P < .001), more commonly women (P < .001), white (P < .001), and more likely American Society of Anesthesiologists Class III (P < .001). The outpatient cohort had fewer 30-day complications, readmissions, and reoperations. The length of stay for both cohorts decreased until 2019, before increasing in 2020 and 2021 for inpatient THAs, while home discharge and operative time increased for both. ConclusionsThe volume of outpatient THA increased almost eightfold after its removal from the IPO lists in 2020. Despite expanding eligibility with older patients and more comorbidities, 30-day complications, readmissions, and reoperations remain low. These findings support the safe transition to outpatient THA with appropriate patient selection and optimization.

Outpatient total hip and knee arthroplasty – Patient expectations versus experience

Aims & objectivesWith modern advancements in surgical techniques and rapid recovery protocols, incidence of outpatient total joint arthroplasty (TJA) is increasing. Previous literature has historically focused on cost, safety, and clinical outcomes, with few studies investigating patient expectations and experiences. The aim of this study was to survey preoperative patient expectations related to outpatient TJA surgery compared with perioperative perceptions and experience. Materials & methodsProspective study of patients undergoing outpatient total hip or knee arthroplasty at a single Tertiary Academic center. Preoperative and postoperative surveys were administered during routine clinic visits. ResultsOne hundred and six patients completed preoperative surveys; 79 completed postoperative surveys and were included in the final data analysis. Fifty (63.3 %) patients reported being aware of outpatient TJA prior to undergoing the procedure. There was no difference between preoperative anticipated pain control and postoperative perceived pain control (6.64 vs. 6.88, p = 0.77). Most postoperative patients (N = 56, 70.9 %) rated outpatient surgery as “much better” or “better” than expected. Most postoperative patients (N = 68, 86 %) would opt to have outpatient surgery again. Fifty-two (65.8 %) of postoperative patients believed outpatient surgery sped up their postoperative rehabilitation. ConclusionFor most patients, the outpatient surgical experience met or exceeded expectations. Nearly 90 % of patients would prefer to have outpatient surgery in the future, further supporting the continued migration of elective arthroplasty away from inpatient sites of care.

Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study

BackgroundSpinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). MethodsWe took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). ResultsAll spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). ConclusionsBoth spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. Level of EvidenceLevel 3, Retrospective Cohort Comparison.

Outpatient Total Ankle Arthroplasty (TAA) as a Safe and Lower Cost Alternative to Inpatient TAA

Category: Ankle; Other Introduction/Purpose: Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. While the Centers for Medicare and Medicaid Services (CMS) have made provisions for outpatient total hip and knee arthroplasty, Medicare patients undergoing total ankle arthroplasty (TAA), until recently, required inpatient admission. There is growing evidence that TAA can safely be performed as an outpatient procedure, with the benefit of decreased healthcare expenses and improved patient satisfaction. Studies have largely investigated direct costs associated with TAA. The purpose of our study was to compare payer costs and complication rates between inpatient and outpatient TAA using a large publicly available for-fee database. Methods: The PearlDiver Database was queried to identify TAA-associated claims for all payer types from January 2010 to April 2021. The claims were identified by the following ICD and CPT codes and analyzed based on service location: CPT-27700, CPT- 27702, ICD-9-P-8156, ICD-10-P-0SRF07Z, ICD-10-P-0SRF0JZ, ICD-10-P-0SRF0KZ, ICD-10-P-0SRG07Z, ICD-10-P-0SRG0JZ, ICD-10-P-0SRG07Z. Baseline comparisons of age, Charleston Comorbidity Index (CCI), geographic region, and payer type were performed. Total reimbursement amount for all associated claims was summed and divided by the number of patients assigned to those claims for the average amount paid per patient. Total cost over a 90-day period was calculated by summing the cost of all claims assigned to patients who underwent TAA within this time frame. The data were analyzed for postoperative infections and readmissions within 90 days as well as failure of TAA defined as conversion to ankle arthrodesis, revision ankle arthroplasty, and/or infection requiring postoperative irrigation and debridement. Results: A total of 7,520 patients who underwent outpatient TAA and 10,772 patients who underwent inpatient TAA were identified. The average age was 54.3 years for outpatients and 63.9 years for inpatients (p Conclusion: In patients undergoing TAA, both average paid per patient and total cost within 90 days were significantly lower in the outpatient setting. Patients who underwent TAA in the outpatient setting as compared to the inpatient setting were younger, with a lower comorbidity index and a different distribution by geographic region and payer type. Complication rates including postoperative infections, readmissions, and arthroplasty failures were significantly lower in the outpatient setting, perhaps due to differences in baseline patient characteristics. These data suggest that outpatient TAA is a safe and lower cost alternative to inpatient TAA.

ERAS in an outpatient total hip arthroplasty program in Belgium: A case series

ERAS in an outpatient total hip arthroplasty program in Belgium: A case series

Inconsistent Classification of “Outpatient” Surgeries Leads to Different Outcomes Following Total Hip Arthroplasty in Medicare Beneficiaries: A Critical Analysis

BackgroundWith rising utilization of outpatient total hip arthroplasty (THA) in older patients including Medicare beneficiaries, the objective was to compare differences in definition including (1) patient demographics; (2) lengths of stay (LOS); and (3) outcomes of “outpatient” (stated status) versus “same-day discharge” (SDD) (actual LOS = 0 days) utilizing a nationwide database. MethodsA national database from 2015 to 2019 was queried for Medicare-aged patients undergoing outpatient THA. Total outpatient THAs (N = 6,072) were defined in one of 2 ways: either “outpatient” by the hospital (N = 2,003) or LOS = 0 days (N = 4,069). Demographics, LOS, discharge destinations, and complications were compared between groups. Logistic regression models computed odds ratios (ORs) for factors leading to complications, readmissions, and nonhome discharges. P values < .008 were significant. ResultsWomen (OR: 1.19, P = .002), diabetes mellitus (OR: 1.31, P = .003), general anesthesia (OR: 1.24, P = .001), and longer operative times (≥95 minutes) (OR: 1.82, P < .001) were associated with ‘outpatient’ designation versus SDD. Within the hospital-defined ‘outpatient’ cohort, 49.1% (983 of 2,003) were discharged the same day (LOS = 0 days), and 21.8% had LOS 2 or more days. The hospital-defined ‘outpatient’ cohort had greater odds of nonhome discharges (6.3 versus 2.8%; OR: 1.88, P < .001) compared to SDD surgeries. The incidence was higher for any complication among hospital-defined ‘outpatient’ designated patients compared to SDD (5.5 versus 3.9%, P = .007). ConclusionsOutpatient surgeries may be misleading and often do not correlate with SDD, as over 20% remain in the hospital 2 or more days. Investigators should quantitatively define the “outpatient” status by actual LOS to allow standardization and results comparison. Level of EvidenceIII.

The Effect of Surgical Approach on the Outcomes of Same-Day Discharge Outpatient Total Hip Arthroplasty at a Single Ambulatory Surgery Center

BackgroundPrimary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting. MethodsA retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%. ResultsComplications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort. ConclusionsIn the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.

Comment on: The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database.

Comment on: The Effect of Intra-articular Hyaluronic Acid Injections and Payer Coverage on Total Knee Arthroplasty Procedures: Evidence From Large US Claims Database.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database.

The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups. This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates. Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites. There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health. III, retrospective cohort study.

Risk Factors for Early Readmission and Reoperation After Outpatient Total Hip Arthroplasty.

Outpatient total hip arthroplasty (THA) is a safe option for select patients. The purpose of this study was to analyze a national database and understand risk factors that lead to unplanned early readmission and reoperation after outpatient THA. The National Surgical Quality Improvement Program database was used to collect outpatient THAs performed from 2013 to 2020. The outpatient setting was defined as a reported hospital length of stay of 23 hours or less. Data variables collected included patient demographics, medical comorbidities, American Society of Anesthesiologists classification, functional status, preoperative laboratory values, National Surgical Quality Improvement Program morbidity probability, and 30-day readmissions and reoperations. A total of 15,055 patients underwent outpatient THA. Mean age was 62.6 years, and 52.1% of patients were men. Mean body mass index was 29.3 kg/m2. The overall rate of readmission was 1.8%, and the reoperation rate was 1.0%. Patients with a 30-day readmission were older (P<.01), with a higher incidence of hypertension (P<.01), steroid use (P<.01), and bleeding disorders (P=.01). Patients with a 30-day reoperation had higher body mass index (P<.01), hypertension (P<.01), and steroid use (P<.01). Regression analysis demonstrated that independent risk factors for readmission were age (P<.01) and steroid use (P<.01). Risk factors for 30-day reoperation were hypertension (P<.01) and steroid use (P<.01). There is a higher risk of early readmission after outpatient THA for older patients with hypertension, bleeding disorders, and steroid use. Patients with hypertension and steroid use have a higher risk for reoperation after outpatient THA. Modifiable risk factors should be addressed preoperatively, with proper patient selection for outpatient THA. [Orthopedics. 2024;47(1):e38-e44.].

A Role for Outpatient Total Joint Arthroplasty During the COVID-19 Pandemic.

Outpatient total joint arthroplasty (TJA) gained favor during the COVID-19 pandemic. Our objective was to critically evaluate the safety and short-term outcomes of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) throughout the pandemic compared with pre-pandemic given their increased use. This was a retrospective review of 941 patients who underwent elective, outpatient TKA and THA at a single institution. Patients were divided into two cohorts: pre-pandemic (N=611) and pandemic (N=330). Data points included demographics, comorbidities, failure of same calendar day discharge (SCDD), and 90-day readmissions and re-operations. The pandemic cohort was older (61.0 vs 59.0 years; P=.001) and had a higher Charlson Comorbidity Index (2 vs 1; P=.004). There were no differences between the pandemic and pre-pandemic cohorts regarding SCDD failures (23.3% vs 21.9%; P=.623) and reoperations (4.2% vs 6.2%; P=.205). The pandemic cohort had a lower readmission rate (4.8% vs 8.2%; P=.056). Overall, patients who had failure of SCDD more commonly underwent TKA than THA (63.5% vs 36.5%; P<.001), were older (63.0 vs 58.5 years; P<.001), had a higher body mass index (30.8 vs 29.9 kg/m2; P=.006) and Charlson Comorbidity Index (2 vs 1; P<.001), had an American Society of Anesthesiologists class greater than 2 (51.2% vs 31.6%; P<.001), received physical therapy later postoperatively (4.15 vs 3.12 hours; P<.001), and had a history significant for myocardial infarction (P=.025), chronic kidney disease (P=.004), or diabetes (P=.003). This study supports broadening indications for outpatient TJA because we found a shift toward older patients with more comorbidities successfully undergoing the procedure. [Orthopedics. 2023;46(5):303-309.].

The Removal of Total Hip Arthroplasty From the Inpatient-Only List has Improved Patient Selection and Expanded Optimization Efforts

BackgroundOn January 1, 2020, the Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the Inpatient-Only (IPO) list. This study evaluated patient demographics and comorbidities, preoperative optimization efforts, and 30-day outcomes of patients undergoing outpatient THA before and after IPO removal. The authors hypothesized that patients undergoing THA post-IPO removal would have improved optimization of modifiable risk factors and equivalent 30-day outcomes. MethodsThere were 17,063 outpatient THAs in a national database stratified by surgery performed before (2015 to 2019: 5,239 patients) and after IPO (2020: 11,824 patients) removal. Demographics, comorbidities, and 30-day outcomes were compared with univariable and multivariable analyses. Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, creatinine, hematocrit, smoking history, and body mass index. The percentage of patients who fell outside the thresholds in each cohort were compared. ResultsPatients undergoing outpatient THA post-IPO removal were significantly older; mean age 65 years (range, 18 to 92) versus 62 (range, 18 to 90) years (P < .01), with a higher percentage of American Society of Anesthesiologists scores 3 and 4 (P < .01). There was no difference in 30-day readmissions (P = .57) or reoperations (P = 1.00). A significantly lower percentage of patients fell outside the established threshold for albumin (P < .01) post-IPO removal, and trended towards lower percentages for hematocrit and smoking status. ConclusionThe removal of THA from the IPO list expanded patient selection for outpatient arthroplasty. Preoperative optimization is critical to minimize postoperative complications, and the current study demonstrates that 30-day outcomes have not worsened post-IPO removal.

Utility of the LET-IN-OUT Clinical Decision Support Tool for Medical Risk Stratification Prior to Outpatient Total Hip or Knee Arthroplasty

BackgroundMusculoskeletal care teams can benefit from simple, standardized, and reliable preoperative tools for assessing discharge disposition after total joint arthroplasty. Our objective was to compare the predictive strength of the Ascension Seton Lower Extremity Inpatient-Outpatient (LET-IN-OUT) tool versus the American Society of Anesthesiologists Physical Status (ASA-PS) score for predicting early postoperative discharge. MethodsWe retrospectively extracted sociodemographic, surgical admission, postoperative day (POD) of discharge, 90-day readmissions, and predictions of the LET-IN-OUT and ASA-PS tools from the electronic records of 563 consecutive hip or knee arthroplasty patients (mean age 65 [SD 9.6], 54% women). Included patients who underwent a total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single health system between June 2020 and March 2021. We performed descriptive statistics and analyzed predictive values of each tool, defining “early discharge” primarily as discharge before the second postoperative day (POD 2), and secondarily as before 24 hours, and on the same calendar day (POD 0) as surgery. ResultsThe LET-IN-OUT tool demonstrated superior predictive power among hip and knee arthroplasty patients compared to the ASA-PS tool for discharge prior to POD 2 (positive predictive value [PPV] 89 versus 83%, positive likelihood ratio [+LR] 2.0 versus 1.2), discharge before 24 hours (PPV 86 versus 70%, +LR 2.9 versus 1.2), and discharge on POD 0 (PPV 34% versus 30%, +LR 1.2 versus 1.1). ConclusionsThe Ascension Seton Lower Extremity Inpatient-Outpatient tool predicted patients suitable for early discharge following THA or TKA and did so more effectively than the ASA-PS score.

Recent Trends and Hotspots in Hip Arthroplasty: A Bibliometric Analysis and Visualization Study of Last Five-Year Publications.

Bibliometric analysis is one of the most prevalent methods for analyzing and predicting research trends of particular subjects. Through a bibliometric analysis, the present study sought to look into and depict the hotspots and research trends in hip arthroplasty research over the previous five years. The Web of Science Core Collection database was used to find studies on hip arthroplasty published between 2018 and 2022. The VOS viewer, Cite Space, and Bibliometrix were used to carry out the bibliometric study and network visualization. During the last five years, 5,708 hip arthroplasty publications were cited 40,765 times. The United States and the Journal of Arthroplasty were the top countries and journals regarding the number of studies, respectively. The top 10 global high-impact documents were determined using the citation ranking and citation burst. The most frequently referenced research revealed the epidemiological aspects of hip arthroplasty, perioperative care after hip arthroplasty, COVID-19, periprosthetic joint infections, opioid medicines, stability, and osteonecrosis were the hot topics in hip arthroplasty research. Keyword burst analysis showed that the research trends in hip arthroplasty through 2022 were patient-reported outcome measures (PROM), depression, racial disparity, and artificial intelligence (AI). The analysis of the subject areas revealed the close connections and relationships between different subject areas, as demonstrated by the figures. The hip arthroplasty research community is very productive and highly centralized. Periprosthetic joint infection, dual-mobility cups, spinopelvic mobility, direct anterior approach, outpatient total hip arthroplasty, polyethylene, periprosthetic fracture, acetabular defects, tranexamic acid, developmental dysplasia of the hip, and safety-net hospitals were recent trends in hip arthroplasty research. Patient-reported outcome measures, depression, racial disparities, and AI were research hotspots in hip arthroplasty.