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Background/aims: Primary simultaneous bilateral total joint arthroplasty (simBTJA) can cause postoperative anemia. Clinicians might hesitate to discharge patients who have large changes in hemoglobin [Hgb], despite Hgb levels remaining above transfusion thresholds. This study was conducted to evaluate if delta Hgb or perioperative blood loss correspond with readmission in primary simBTJA patients not transfused perioperatively. Methods: From 2015 - 2020, a retrospective chart review of primary simultaneous bilateral total hip/knee arthroplasty cases was conducted. Preoperative and postoperative Hgb levels were obtained from our database or chart review. Exclusion criteria comprised patients who had a preoperative transfusion or transfusion postoperatively during their surgical admission, and patients not discharged home. Outcomes included whether delta Hgb or perioperative blood loss were predictive of 90-day readmission postoperatively, postoperative anemia, and transfusion during readmission. Results: The 510 individuals undergoing primary simBTJA possessed an average preoperative Hgb of 14.1 g/dL, starting blood volume of 5012 mL, postoperative Hgb of 10.0 g/dL, delta Hgb of 3.90 g/dL, and perioperative blood loss of 1403 mL. 19 patients (3.73 %) were readmitted, with none requiring transfusion. When constructing receiver operating characteristic (ROC) curves predicting readmission from delta Hgb, a threshold of 4.1 g/dL had an area under the curve (AUC) of 0.454, a sensitivity of 0.473, and a specificity of 0.56. For ROC curves predicting readmission from perioperative blood loss, a threshold of 1144 mL had an AUC of 0.453, a sensitivity of 0.842, and a specificity of 0.297. Similar AUCs, sensitivities, and specificities were obtained when adjusting ROC curves for preoperative Hgb or starting blood volume. Conclusions: Delta Hgb and perioperative blood loss do not predict 90-day readmission after primary simBTJA in patients not transfused perioperatively. Patients with a large delta Hgb but stay higher than a 7 g/dL restrictive transfusion threshold may have a strong capacity to overcome postoperative anemia.
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BACKGROUND: Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions. METHODS: A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission. RESULTS: Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787). CONCLUSION: The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.
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Anemia , Artroplastia de Reemplazo de Rodilla , Enfermedades Cardiovasculares , Anemia/epidemiología , Anemia/etiología , Anemia/terapia , Artroplastia de Reemplazo de Rodilla/efectos adversos , Transfusión Sanguínea , Hemoglobinas/análisis , Humanos , Alta del Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND: In 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only list, resulting in payment through the Outpatient Prospective Payment System with an average $3157 reduction. The purpose of this study is to determine if the reimbursement is justified by comparing the difference in facility costs between inpatient and outpatient TKAs. METHODS: We identified 4496 consecutive primary TKA procedures performed at 2 hospitals from 2015 to 2019. Itemized facility costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with a length of stay of less than 2 midnights (3851, 86%). Patient demographics, comorbidities, and itemized costs were compared between groups. A multivariate regression analysis was performed to determine the independent effect of outpatient status on true facility costs. RESULTS: Outpatient TKA patients had lower mean postoperative personnel costs ($1809 vs $947, P < .001), supply costs ($4347 vs $4229, P < .001), and overall total facility costs ($7371 vs $6937, P < .001) than inpatient TKA patients. Controlling for a younger patient cohort with fewer medical comorbidities, outpatient status was associated with a reduction in total facility costs of $972 (95% confidence interval $883-$1060, P < .001) compared to inpatient TKA. CONCLUSION: Outpatient TKA costs hospitals nearly $1000 per patient less than inpatient TKA, yet the average difference in Medicare reimbursement for an outpatient procedure is $3157 less per patient. Centers for Medicare and Medicaid Services should reconsider the Outpatient Prospective Payment System classification of TKA to better incentivize surgeons to perform TKA as a lower cost outpatient procedure when safe and appropriate.
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Artroplastia de Reemplazo de Rodilla , Sistema de Pago Prospectivo , Anciano , Centers for Medicare and Medicaid Services, U.S. , Humanos , Medicare , Pacientes Ambulatorios , Estados UnidosRESUMEN
Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].
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Artroscopía , Manejo del Dolor/métodos , Dolor Postoperatorio/etiología , Manguito de los Rotadores/cirugía , Acetaminofén/uso terapéutico , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Bloqueo del Plexo Braquial , Humanos , Ketorolaco/uso terapéutico , Masculino , Persona de Mediana Edad , Oxicodona/uso terapéutico , Estudios ProspectivosRESUMEN
BACKGROUND: Web-based physical therapy (WBPT) is a potential means to reduce costs following total knee arthroplasty (TKA). Although outcomes data support the use of self-directed therapy after TKA, there is a paucity of literature evaluating its cost-effectiveness. This study aimed to determine utilization trends of either outpatient physical therapy (OPPT) or WBPT after TKA, assess the outcomes of patients based on their use of WBPT, OPPT, or both, and evaluate OPPT costs based on the amount of WBPT used. METHODS: A retrospective review of 701 patients (731 TKAs) was performed. Patients were given a prescription for OPPT and access to a self-directed WBPT program. Functional scores were obtained preoperatively and 6 months postoperatively, and the rate of manipulation under anesthesia (MUA), range of motion, and PT costs were recorded. RESULTS: About 49.8% of patients utilized WBPT, 34.7% of patients utilized WBPT and OPPT, and 23% of patients utilized neither source of therapy. Patients that utilized both WBPT and OPPT demonstrated the lowest rates of MUA. There were no differences in postoperative outcomes based on the number of WBPT logins. Overall, PT cost was 3.4× higher for those that underwent MUA. Subgroup analysis of patients that utilized WBPT revealed that the cost and number of PT visits decreased as the number of logins increased. Patients younger than 65 utilized more WBPT and OPPT while demonstrating worse outcomes (lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement postoperative scores and more MUAs). CONCLUSION: WBPT can be an effective option to offset costs associated with OPPT, without compromising outcomes.
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Artroplastia de Reemplazo de Rodilla , Osteoartritis de la Rodilla , Análisis Costo-Beneficio , Terapia por Ejercicio , Humanos , Internet , Articulación de la Rodilla/cirugía , Modalidades de Fisioterapia , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Bone morphogenetic protein (BMP) signaling is a critical regulator of cartilage differentiation and endochondral ossification. Gain-of-function mutations in ALK2, a type I BMP receptor, cause the debilitating disorder fibrodysplasia ossificans progressiva (FOP) and result in progressive heterotopic (extraskeletal) endochondral ossification within soft connective tissues. Here, we used murine mesenchymal progenitor cells to investigate the contribution of Alk2 during chondrogenic differentiation and heterotopic endochondral ossification (HEO). Alk2(R206H/+) (gain-of-function), Alk2(CKO) (loss-of-function), and wild-type mouse embryonic fibroblasts were evaluated for chondrogenic potential. Chondrogenic differentiation was accelerated in Alk2(R206H/+) cells, due in part to enhanced sensitivity to BMP ligand. In vivo, Alk2(R206H/+) cells initiated robust HEO and recruited wild-type cell contribution. Despite expression of other type I BMP receptors (Alk3 and Alk6), chondrogenesis of Alk2(CKO) cells was severely impaired by absence of Alk2 during early differentiation. Alk2 is therefore a direct regulator of cartilage formation and mediates chondrogenic commitment of progenitor cells. These data establish that at least one effect of ALK2 gain-of-function mutations in FOP patients is enhanced chondrogenic differentiation which supports formation of heterotopic endochondral bone. This establishes ALK2 as a plausible therapeutic target during early chondrogenic stages of lesion formation for preventing heterotopic bone formation in FOP and other conditions.