Same Day Total Knee Arthroplasty : Pro: I’m Still Doing It! My Patients Love It! Adolph V. Lombardi, Jr., MD, FACS Joint Implant Surgeons, Inc., White Fence Surgical Suites, The Ohio State University, Mount Carmel Health System, Midwest Training & Development Services, New Albany, Ohio
Adolph V. Lombardi, Jr. Disclosure Consultant: ♦ Zimmer Biomet Royalties: ♦ Zimmer Biomet; Innomed Research Support: ♦ Zimmer Biomet; SPR Therapeutics Investment Interest (minority): ♦ SPR Therapeutics, Joint Development Corporation, Elute, Inc. Publications Editorial Boards: ♦ Journal of Arthroplasty; Journal of Bone and Joint Surgery - American; Clinical Orthopaedics and Related Research; Journal of the American Academy of Orthopaedic Surgeons; Journal of Orthopaedics and Traumatology; Surgical Technology International; The Knee Boards: ♦ Operation Walk USA; The Hip Society; The Knee Society; Mount Carmel Education Center at New Albany
Managing Patients Upfront: Indication vs Optimization Is this patient indicated for surgery? ♦ Sufficient symptoms interfering with ADL, work or recreation, QOL ♦ Inability of alternative treatment to resolve symptoms ♦ Objective evidence of joint disease amenable to surgical correction Develop a method to assess: Is this patient optimized for outpatient surgery? ♦ Should it be scheduled or delayed based on: ♦ Psychologically and medically fit for surgery ♦ Adequate support for home environment 1. Diabetes: Hgb A1c if >7.9 delay and refer 2. Smoker: if YES then refer to smoking cessation 3. BMI: if >40 refer for counseling, metabolic consult 4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for workup or blood management 5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize 6. Narcotic dependence, manage upfront 7. Anticoagulation history or need perioperatively 8. Lack of supportive home environment
Does the patient have Who’s a Candidate for an ongoing medical issue that cannot be Outpatient Arthroplasty optimized? at the ASC? No Yes Does the patient have Postpone an organ failure? surgery until No medically Does the patient have optimized adequate support upon discharge? Yes Patient is not a candidate for Yes No outpatient surgery and, if medically stable, surgery should be Surgery can be safely Consider performed at a hospital and the performed as an surgery at patient observed for 23 hours outpatient hospital
Medical Optimization: The Surgeon’s Role Identify Organ Failure: ♦ Congestive heart failure ♦ COPD ♦ Chronic renal insufficiency ♦ Hepatobiliary disease ♦ Dementia / seizure disorder ♦ Hematopoietic disease ♦ History of anemia
Medical Optimization: The Internist’s Role Make sure organ failure not missed… Medical Optimization: ♦ Referrals to specialists • Cardiology, pulmonology, hematology ♦ Identify and optimize OSA ♦ Hemoglobin management ♦ VTE risk stratification ♦ Glycemic control/A1C ♦ Smoking cessation
Location of Surgery A review process has been developed in collaboration with Orthopaedic Surgeons, Medical Consultants, and Anesthesia Initial triage is done at the time of visit with the Orthopaedic Surgeon Suitability for chosen facility is confirmed at the time of Preadmission Testing (PAT) Should the medical consultant feel that patient’s characteristics warrant change in location, this is communicated directly to surgeon and anesthesia
Outpatient Knee Arthroplasty Experience Joint Implant Surgeons / White Fence Surgical Suites June 2013 – December 2016; 4 surgeons ♦ 2991 knee arthroplasties in 2373 patients 1344 partial knee arthroplasty • 1589 primary TKA • 58 revision TKA • ♦ Gender: 43% males (1014) : 57% females (1359) • ♦ Mean Age: 59.4 years (SD 7.0, range 25-86) ♦ Mean BMI: 33.9 kg/m 2 (SD 7.1, range 17-63)
Overnight Stays / Acute Transfers 2755 (92.1% ) discharged same day 10 (0.3% ) transferred to acute hospital 226 (7.6% ) stayed overnight ♦ 74 (2.5% ) stayed for convenience ♦ 154 (5.1% ) stayed or transferred for a medical reason 43 respiratory issues 4 cardiac • • 24 OSA 2 cerebrovascular • • 29 nausea / vomiting 13 other (in 12 patients) • • 7 urinary related 4 traumatic falls • • 4 pain control 3 antibiotic administration • • 8 muscle strength 1 pseudoseizures • • 6 difficulty waking up 1 dizziness • • 7 wound issues 1 patient - bilateral TKA (2) • • 4 arrhythmia 2 difficult history • • 3 blood pressure control •
Major Co-Morbidities 1. Coronary artery disease 2. Valvular heart disease 3. Arrhythmia 4. History of venous thromboembolism 5. Obstructive sleep apnea 6. Chronic obstructive pulmonary disease 7. Asthma 8. Frequent urination 9. Renal disease
Preoperative Major Co-Morbidities 58% (1729) ≥1 Major CM 3% (81) Renal Disease 19% (569) Frequent Urination 11% (333) Asthma 18% (531) COPD 16% (474) OSA 5% (147) VTE 18% (531) Arrhythmia 1% (15) Valvular 6% (174) CAD 0% 10% 20% 30% 40% 50% 60% 70%
Overnight Stay or Transfer for Medical Reason by Preoperative Major Co-Morbidities (109 of 1729) 6% ≥1 Major CM 7% (6 of 81) Renal Disease 6% (33 of 569) Frequent Urination 10% (32 of 333) Asthma 8% (42 of 536) COPD 7% (32 of 474) OSA 3% (5 of 147) VTE 8% (40 of 531) Arrhythmia No Stay or Convenience 13% (2 of 15) Valvular Ovenight or Transfer for Medical 12% (20 of 174) CAD 0 200 400 600 800 1000 1200 1400 1600 1800
Risk of Overnight Stay for Medical Reason by Major Co-morbidity Major Co- Overnight Medical Relativ 95% CI P value Odds 95% CI P value Morbidity with vs without CM e Risk Ratio CAD 11.5% vs 5.5% 2.41 1.6-3.8 0.0001 2.60 1.6-4.3 0.0002 Valvular 13.3% vs 5.1% 2.83 0.7-12.5 0.1677 2.86 0.6-12.8 0.1693 Arrhythmia 7.5% vs 4.6% 1.50 1.1-2.0 0.0043 1.68 1.2-2.4 0.0066 VTE 3.4% vs 5.2% 0.65 0.3-1.6 0.3334 0.64 0.3-1.6 0.3295 OSA 6.8% vs 4.8% 1.33 1.0-1.8 0.0778 1.42 1.0-2.1 0.0868 COPD 7.8% vs 4.6% 1.57 1.2-2.1 0.0011 1.78 1.2-2.6 0.0021 Asthma 9.6% vs 4.6% 1.96 1.4-2.7 0.0001 2.21 1.5-3.3 0.0001 Frequent 5.8% vs 5.0% 1.13 0.8-1.6 0.4288 1.17 0.8-1.7 0.4354 Urination Renal Disease 7.4% vs 5.1% 1.47 0.7-3.3 0.3542 1.49 0.6-3.5 0.3542 Any 6.3% vs 3.6% 1.24 1.1-1.4 0.0001 1.82 1.3-2.6 0.0010
Major Complications within 48 Hours 26 (0.9% ) including 10 patients transferred to acute ♦ 2 CVA (both transferred) ♦ 2 atrial fibrillation (both transferred) ♦ 3 pulmonary issues (all transferred) ♦ 2 EKG changes (transferred, negative for MI) ♦ 1 possible ileus, continuous N/V (transferred) ♦ 1 postoperative anemia ♦ 4 trauma secondary to falling (3 inpatient, 1 at home) ♦ 4 pain control post discharge ♦ 2 confirmed VTE ♦ 3 to ER for VTE symptoms with negative testing ♦ 1 allergic reaction to medication ♦ 1 I&D for hematoma / wound dehiscence
Unplanned Care after 48 Hours, within 90 days 22 (0.7% ) ♦ 4 pain control post discharge ♦ 6 confirmed VTE ♦ 6 allergic reaction (5 to medication; 1 unknown cause) ♦ 1 urinary tract infection ♦ 1 urinary retention ♦ 1 chest pain ♦ 1 constipation/ileus ♦ 1 cellulitis of the foot & ankle ♦ 1 panic attacks
Surgical Complications Requiring Treatment Days 3-90 30 (1.1% ) ♦ 15 wound revisions ♦ 9 I&D for hematoma or early infection ♦ 1 two-staged exchange for infection ♦ 2 periprosthetic fracture ♦ 2 arthroscopic removal of loose bodies ♦ 1 revision UKA to TKA for instability
90-Day Mortality 2 patient deaths within 90 days ♦ 1 (POD 33) cause unknown – seen at ER POD 7 for severe pain with “pop” from bending over, negative for fracture or dislocation ♦ 1 (POD 48) cause unknown – seen at 6 week postop office visit & was doing well
Musculoskeletal Specialty Hospital (MCNA) 30-day Readmissions 2015 2016 Total Primary Total Hip 1.0% 1.5% 1.2% (6 of 604) (9 of 598) (15 of 1202) Primary Total Knee 0.8% 0.7% 0.8% (8 of 977) (8 of 1082) (16 of 2059) Total 0.9% 1.0% 1.0% (14 of 1581) (17 of 1680) (31 of 3261)
Outpatient TJA In medically optimized patients, despite a large proportion of comorbidities, outpatient TJA is associated with a low rate of medical and surgical complications Presence of major comorbidity was associated with need for extended observation / overnight stay Patient education, medical optimization, and multimodal program to mitigate side effects and reduce narcotic need results in ability to safely perform outpatient TJA in a large proportion of patients without need for a standardized risk assessment score.
Preoperative Care Yes 97.3% Were you contacted by our staff prior to… No 98.4% If yes, did the nursing staff clearly explain… 0% 20% 40% 60% 80% 100% Prior to my visit, my financial 54% 27% Excellent responsibilities were discussed and my… Good The directions to the facility were clear 74% 18% Average and accurate. Fair The registgration and business staff were Poor 84% 14% courteous and helpful. My waiting time prior to surgery was 75% 17% reasonable and as expected. 0% 20% 40% 60% 80% 100%
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