Andrew J. Lovy

Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends

BACKGROUND This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination. METHODS Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables. RESULTS A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001). CONCLUSION SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.

Unipolar vs Bipolar Hemostasis in Total Knee Arthroplasty: A Prospective Randomized Trial

The purpose of this study was to investigate whether unipolar or bipolar hemostasis is more effective in reducing blood loss associated with primary total knee arthroplasty. We randomized 113 consecutive patients undergoing primary total knee arthroplasty into unipolar and bipolar hemostasis treatment groups. The mean postoperative drain output in the unipolar group was 776.5 mL compared with 778.7 mL and was not statistically significant (P = .97). There were no statistically significant differences in postoperative day 1 through 3 hemoglobin level (P = .2-.6) or hematocrit (P = .17-.46) values. The transfusion requirement in the unipolar group was 36% and 40% in the bipolar group (P = .67). Use of bipolar sealer compared with standard unipolar electrocauterization showed no significant difference in postoperative drain output, postoperative hemoglobin level and hematocrit values, or transfusion requirements.

Infection Rate Following Total Joint Arthroplasty in the HIV Population

The purpose of this study is to review a large series of HIV-infected patients who underwent total joint arthroplasty and identify potential risk-factors for infection. Sixty-nine HIV-infected arthroplasty cases were analyzed with 138 matched controls. Deep infection rate following total hip or knee arthroplasty was 4.4% (3 of 69) among HIV cases compared to 0.72% (1 of 138) among controls, yielding a non-significant 6.22 times increased odds of infection (95% CI 0.64-61.0, P=0.11). Kaplan-Meier survival curves for infection free survival and revision free survival revealed non-significantly decreased survival in HIV cases compared to controls (P=0.06 and P=0.09). Our results suggest that the rate of early joint infection following primary total joint arthroplasty in the HIV-infected population is lower than reported in a number of previously published studies.

Histologic retrieval analysis of a porous tantalum metal implant in an infected primary total knee arthroplasty.

Porous tantalum (Zimmer, Inc, Warsaw, Ind) has the theoretical advantage of improved biologic fixation because of its high porosity, interconnected pore space, and modulus of elasticity. We present a case report documenting the retrieval and bone ingrowth analysis of a porous tantalum tibial component in an infected total knee arthroplasty. Results demonstrated a significantly larger amount of bone ingrowth present in the tibial posts (36.7%) when compared with the bone ingrowth into the tibial baseplate (4.9%) (P < .001). The data suggest that bone ingrowth seen in the plugs as well as baseplate was suggestive of viable bone tissue with healthy bone marrow, osteocytes, and lamella, resulting in a well-fixed tibial implant even at revision surgery for an infected total knee arthroplasty.

Outcomes, complications, utilization trends, and risk factors for primary and revision total elbow replacement.

BACKGROUND Using a validated database, 30-day complications of primary and revision total elbow arthroplasty (TEA) were analyzed to identify risk factors of adverse events. METHODS Primary and revision TEAs from 2007 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day adverse events were assessed using preoperative and intraoperative variables. RESULTS The study reviewed 189 primary and 53 revision TEA patients. Fracture (34%), osteoarthritis (24%), and rheumatoid arthritis (23%) were the most common indications for TEA. Adverse event rate was similar in primary and revision TEA (12% vs. 15%; P = .49), and infectious complications occurred in 3.2% of primary TEAs and 7.5% of revision TEAs (P = .23). Bivariate analysis of risk factors for 30-day adverse events identified dependent functional status in primary TEA (P = .03) and age in revision TEA (P = .02). Multivariate analysis of primary TEA revealed that adverse events were significantly less likely with rheumatoid arthritis compared with osteoarthritis etiology (odds ratio, 0.15; P = .02), and smoking was associated with an increased chance of infection (odds ratio, 6.96; P = .03). Revision TEA was not associated with an increased 30-day adverse event or infection rate compared with primary TEA in multivariate analysis. Among primary and revision TEA patients, dependent functional status (P = .02) and hypertension (P = .04) were independent predictors for adverse events. CONCLUSION Modifiable risk factors should be addressed before TEA to limit postoperative complications as well as cost. The risk of short-term complications after revision TEA is comparable to that of primary TEA.

Risk Factors Predict Increased Length of Stay and Readmission Rates in Revision Joint Arthroplasty

BACKGROUND This study aimed to identify risk factors for 30-day readmission and extended length of stay (LOS) in revision total knee (RKA) and hip (RHA) arthroplasty patients. METHODS Patients who underwent RKA or RHA from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day readmission and extended LOS (>75th percentile) were assessed using preoperative and intraoperative variables. RESULTS A total of 4977 RKA and 5135 RHA patients were reviewed. The most common causes for revision were mechanical (52% RKA, 52% RHA), infection (13% RKA, 8% RHA), dislocation (6% RKA, 13% RHA), and fracture (1% RKA, 4% RHA). Rate of readmission for RKA patients (6.4%; 318 patients) was lower than for RHA patients (8.0%; 409 patients) (P = .002). Multivariate analysis identified severe adverse event before discharge, male sex, pulmonary disease, stroke, cardiac disease, and American Society of Anesthesiologists class 3 or 4 as significant predictors of readmission (all P ≤ .03). Surgical complications were the more common cause of readmission for both groups. Multivariate analysis of extended LOS identified infection or fracture etiology relative to mechanical loosening etiology, functional status, body mass index greater than 40 kg/m2, history of smoking, diabetes, cardiac disease, stroke, bleeding-causing disorders, wound class 3 or 4, and American Society of Anesthesiologists class 3 or 4 (all P ≤ .05) as independent predictors. CONCLUSION Modifiable risk factors should be addressed prior to revision total joint arthroplasty to reduce 30-day readmissions and LOS. Future P4P revision arthroplasty models should incorporate procedural diagnosis as rates of readmission and extended LOS significantly differ across procedural etiologies.

Outcome of arthroscopic reduction association of the scapholunate joint

This study evaluates the arthroscopic reduction association scapholunate technique and outcomes. A total of 18 patients with chronic scapholunate instability with mean follow-up of 36 months were reviewed. Postoperatively, the mean visual analogue score was 2.5 and the mean DASH score was 8. The grip strength was 27 kg on the operative side compared with 32 kg on the uninjured side. The mean wrist flexion was 46° and extension was 56°. Seven patients had complications. Six patients had scapholunate joint widening, one had windshield-wipering of the screws with loss of reduction, and two demonstrated progression of scapholunate advanced collapse deformity. Four patients underwent revision surgeries: two revision arthroscopic reduction association scapholunates and two proximal row carpectomies. A preoperative scapholunate gap of greater than 5 mm and the presence of scapholunate advanced collapse Grade I were both predictive of a complication or revision surgery. Patients with a scapholunate gap of greater than 5 mm or scapholunate advanced collapse had statistically higher complications rates. Level of Evidence IV.

Preliminary development of a clinical decision rule for acute aortic syndromes

OBJECTIVE Patients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule. METHODS We retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm. RESULTS Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). CONCLUSIONS Our results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.

Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors

BACKGROUND Given the rising incidence of revision total joint arthroplasty (RJR), bundled payments will likely be applied to RJR in the near future. This study aimed to compare postdischarge adverse events by discharge destination, identify risk factors for discharge placement, and stratify RJR patients based on these risk factors to identify the most appropriate discharge destination. METHODS Patients that underwent revision total hip or knee arthroplasty from 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Analysis of risk factors was assessed using preoperative and intraoperative variables. RESULTS A total of 9973 RJR patients from 2011 to 2013 were included for analysis. The most common discharge destination included home (66%), skilled nursing facility (SNF; 23%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed higher rate of postdischarge 30-day severe adverse events (6.1% vs 4.1%, P < .001) and unplanned readmissions (9.3% vs 6.1%, P < .001) in nonhome vs home patients. In multivariate analysis, SNF and IRF patients were 1.30 and 1.51 times more likely to suffer an unplanned 30-day readmission relative to home patients (P ≤ .01), respectively. After stratifying patients by number of significant risk factors and discharge destination, IRF patients consistently had significantly higher rates of unplanned 30-day readmission than home patients (P ≤ .05). CONCLUSION RJR patients who are discharged to SNF or IRF have significantly increased risk for unplanned readmissions as compared with patients discharged home. Across risk levels, home discharge destination (when feasible) is the optimal strategy compared with IRF, although the distinction between SNF and home is less clear.

Teaching Bioethics: The Tale of a “Soft” Science in a Hard World

Background: Although bioethics is considered essential to the practice of medicine, medical students often view it as a “soft” subject that is secondary in importance to the other courses in their basic science and clinical curriculum. This perspective may be a consequence of the heavy reliance on students’ aptitude in the quantitative sciences as a criterion for entry into medical school and as a barometer of academic success after admission. It is exacerbated by the widespread impression that bioethics is imprecise and culturally relativistic. Summary: In an effort to redress this imbalance, we propose an approach to teaching bioethics to medical students which emphasizes that the intellectual basis and the degree of certainty of knowledge is comparable in all medical subjects ranging from basic science courses to clinical rotations to bioethics tutorials. Conclusions: Adopting these pedagogical steps may promote greater integration of the various elements—bioethics and clinical science—in the medical school curriculum.