As Fleischman et al. observe in the January 17, 2018 edition of The Journal, “there is a prevailing belief that patients living alone cannot be safely discharged directly home after total joint arthroplasty [TJA].” Not so, according to results of their Level II prospective cohort study.
The authors reviewed outcomes among a cohort of 769 patients undergoing lower-extremity arthroplasty who were discharged home, 138 of whom were living alone. While patients living alone more commonly stayed an additional night in the hospital and utilized more home-health services than patients living with others, there were no between-group differences in 90-day complication rates or unplanned clinical events, including readmissions.
These findings are reassuring, but all patients discharged home after a lower-limb arthroplasty need some support with meal preparation, personal hygiene, and other activities of daily living for the first 10 to 14 days. Clinicians should therefore adequately assess the local support system for each patient living alone in terms of family, neighbors, or friends to be sure the patient will be safe if discharged home. This crucial determination is a team exercise involving nursing, the surgeon, physical and occupational therapists, and a social worker. Fleischman et al. implicitly credit the “nurse navigator” program at their institution (Rothman Institute) with coordinating this team effort.
Investigation into these issues is very important as the orthopaedic community works to lower the costs of arthroplasty care while improving patient safety and satisfaction. If the appropriate support is in place, patients and clinicians alike would prefer that patients sleep in their own beds after discharge from joint replacement surgery.
Marc Swiontkowski, MD
Here’s one thing about which medical studies have been nearly unanimous: Smoking is a health hazard by any measure. In the February 15, 2017 edition of The Journal of Bone & Joint Surgery, Tischler et al. put some hard numbers on the risk of smoking for those undergoing total joint arthroplasty (TJA).
After controlling for confounding factors, the authors of the Level III prognostic study found that:
- Current smokers have a significantly increased risk of reoperation for infection within 90 days of TJA compared with nonsmokers.
- The amount one has smoked, regardless of current smoking status, significantly contributed to increased risk of unplanned nonoperative readmission.
In a commentary on the Tischler et al. study, William, G. Hamilton, MD says, “…as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health.”
The incidence of primary total knee and hip arthroplasty is increasing steadily. While the success rates of these procedures are remarkable, failures do occur, and periprosthetic joint infection is the leading culprit in such failures. The standard treatment when deep infection strikes is a two-stage revision.
On Monday, November 14, 2016 at 8:00 PM EST, The Journal of Bone & Joint Surgery (JBJS) will host a complimentary webinar that examines prognostic factors affecting the success of two-stage revision arthroplasty for infected knees and hips.
- Tad M. Mabry, MD, coauthor of a matched cohort study in JBJS, will examine the impact of morbid obesity on the failure of two-stage revision TKA.
- JBJS author Antonia F. Chen, MD, will discuss results from a retrospective study that revealed an association between positive cultures at the time of knee/hip component reimplantation and the risk of subsequent treatment failure.
Moderated by JBJS Deputy Editor Charles R. Clark, MD, the webinar will include additional perspectives from two expert commentators—Daniel J. Berry, MD and Andrew A. Freiberg, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.
Seats are limited, so register now!
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD.
In a recent issue of JAMA, Dummit et al. analyzed cost and quality results from the Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative. The authors compared joint-replacement results between hospitals that voluntarily participate in the BPCI program versus matched comparison hospitals that do not participate. Nearly 60,000 lower extremity joint replacement procedures from each hospital type were included in the analysis.
Medicare payments declined over time in both groups of hospitals, but the authors noted a greater decline in costs among the BPCI hospitals, primarily due to reduced utilization of post-institutional acute care. There were no statistical differences in quality between the BPCI hospitals and comparison hospitals, as measured by unplanned admissions, emergency department visits, and mortality at both 30 and 90 days. These results echo those reported by other pilots in the United States and suggest that similar programs could reduce cost per episode of care without compromising quality.
However, even proponents of the new programs are cautious. For example, in his JAMA editorial, Elliot Fisher, MD warns readers that because BPCI is a voluntary program, the results may not reflect the true impact of a more widespread bundled-payment model. The incentives, he argues, could end up contributing to volume increases or shifts toward healthier—and “more profitable”—patients. As Fisher concludes, “Bundled payments leave the overarching incentive to increase volume solidly in place.”
In a separate JAMA Viewpoint article, Ibrahim et al. warn that another CMS program, the Comprehensive Care for Joint Replacement (CJR) model, could unintentionally amplify already existing racial disparities in elective joint replacement. CJR is a mandatory initiative in 67 randomly selected US metropolitan areas. The authors say that CJR might improve postoperative quality of care for minority patients after joint replacement, but that the program could also end up favoring healthier, well-insured patients.
Overall, at this early stage, these two CMS models offer promising, comprehensive approaches to joint replacement that may prove cost-saving without comprising quality of care. Results like the ones published by Dummit et al. are hopeful, but longer-term, outcomes-based, and cost-focused studies that include epidemiologic and racial impact must be performed as we move forward carefully.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD and Shahriar Rahman, MS.
Recovery after surgery is an outcome that matters to everyone. The concept of enhanced recovery after surgery (ERAS) was first introduced in 1997 in Denmark by general surgeon Henrik Kehlet. The key objective is to accelerate postoperative recovery, reduce the length of hospital stay, and improve patient experience and clinical outcomes.
There are four key elements to ERAS:
- Optimizing preoperative care – The patient, surgeon, anesthesiologist, and nurses form a single team. A preoperative plan and classes help patients manage expectations.
- Reducing the physical stress of surgery –This may include minimally invasive techniques, reduced surgical times, optimized anesthetic techniques (e.g., spinal anesthesia or blocks), and maintenance of normovolemia. Traditionally, patients have nothing by mouth for many hours prior to surgery. ERAS, however, allows patients to receive clear fluids by mouth up to two hours prior to the operation. This practice has proven to be of limited risk and may better optimize fluid balance perioperatively.
- Enhancing postoperative comfort – This entails effective multimodal analgesia and prophylaxis against nausea. Narcotics are minimized, especially in elderly patients. A well-structured and consistent plan is developed among the patient, physicians, nurses, social workers, family/ caretakers, and physical therapists. Orthopaedic-floor staff standardize protocols to provide consistent, structured care with well-defined roles.
- Optimizing postoperative care – Early mobilization, normal feeding and hydration, and unambiguous discharge and post-discharge instructions are the goals here. Many ERAS programs also employ a Bring Your Own Gum initiative. Evidence suggests that chewing gum diminishes postoperative gastrointestinal dysfunction by preserving efferent vagal nerve activity, even when the surgical procedure did not involve the gastrointestinal tract.
The ERAS protocol was used initially in colorectal patients. A 2014 ERAS pilot of colorectal patients at Boston’s Brigham and Women’s Hospital found lower rates of complications after surgery. Cardiac events dropped by as much as 90 percent; there were 66 percent fewer surgical site infections, and patients left the hospital two days earlier on average. The Brigham is expanding ERAS guidelines to at least three other departments, and a study by Dwyer et al. in 2012 found that ERAS benefits seem to be universal and confer an advantage regardless of the patient’s preoperative condition.
Elective total joint arthroplasty (TJA) is one area of orthopaedics that has adopted several principles of ERAS. Reilly et al. (2005) were able to show that ERAS is beneficial in the treatment of patients undergoing unicompartmental knee replacement. As ERAS adoption increases among the orthopaedic surgery specialty, it is reasonable that its implementation may extend to subspecialties beyond TJA, such as hip fractures and upper extremity surgery. Macfie et al. (2012) demonstrated ERAS benefits in patients with a fractured femoral neck.
The improvements to quality of care and efficiency that are gained by implementing ERAS programs are largely due to changes in the underlying organizational structure of hospitals. To make further progress in orthopaedic care, we have to not only introduce new interventions that are proven beneficial, but also (and perhaps more importantly) stop doing things that are not beneficial and may even cause harm to patients.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh.