Aims. Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients’ pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). Methods. This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. Results. The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). Conclusion. We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology. Cite this article: Bone Joint J 2024;106-B(3 Supple A):24–30

Aims. Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods. A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results. Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion. Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908

Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Aims. The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis. Methods. Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year. Results. Mean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients. Conclusion. ERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key. Cite this article: Bone Jt Open 2021;2(11):966–973

Aims. In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip. Methods. The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression. Results. A total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS. Conclusion. Surgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS. Cite this article: Bone Jt Open 2021;2(8):679–684

Abstract. Background. The European population is consistently getting older and this trend is expected to continue with fastest rise seen in those over 85 years old. As a consequence there will be more nonagenarians (over 90 years old) having lower limb arthroplasty. Objectives. To compare the length of stay, readmission and one year mortality between nonagenarians and people aged between 70 to 80 years after having lower limb arthroplasty. Methods. Retrospective review of patients electronic records over 90 years following total knee replacement (TKR) or total hip replacement (THR). The length of stay after surgery, 30 day readmission rate and one year mortality were compared with control group aged between 70 to 80 years who had lower limb arthroplasty during the same period. Results. There were 31 nonagenarians with mean age of 91.6 years and the control group consisted of 31 patients with the mean age of 74.6 years. The average length of stay was 5 days in the nonagenarians compared to 4 days in the younger group. There was no difference in the 1 year mortality. 30 day readmission's was 16% in the older cohort and 5% in the younger. There was an increase in trend of nonagenarians having lower limb arthroplasty over the years. Conclusions. There is increasing number of nonagenarians undergoing lower limb arthroplasty. Nonagenarians and those aged between 70 to 80 years have comparable length of stay and 1 year mortality but higher rate of readmissions after lower limb arthroplasty

Introduction. The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons. Methods. A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS. Results. The mean total length of stay was 4 days (1 to 42). The top three reasons for PLOS were social services, day-before-surgery admission, and slow to mobilize. Social services accounted for 1,224 excess bed days, almost half (49.2%, 1,224/2,489) of the sum of excess bed days. Conclusion. A preadmission discharge plan, plus day of surgery admission and mobilization on the day of surgery, would have the potential to significantly reduce length of stay without compromising patient care. Cite this article: Bone Joint Open 2020;1-8:488–493

Introduction. There is a drive to reduce length of stay in children undergoing limb reconstruction but a reduction in community physiotherapy input and a consequent pressure to ensure children are as independent as possible prior to discharge. This study aims to look at time taken and potential factors effecting the achievement of pre-set mobility goals and length of stay in this population. Materials and Methods. Between June 2018 and November 2021 data was collated for patients who underwent limb reconstruction at Great Ormond Street hospital. 77 patients were reviewed. Data collected included type and location of lengthening device and length of stay. A modified version of the Goal Attainment Score (GAS) was used and included 3 goals which the child needed to achieve within 7 days post-operatively. Results. All children achieved their goals within the 7 days. Length of stay with intramedullary devices was shorter than with external fixators (average of 5 vs 10 days). For children with frames, including the ankle significantly increased hospital stay, whereas inclusion of the knee had no significant effect, and. Bilateral frames were associated with a longer stay. Conclusions. The use of GAS with pre-defined clinically driven goals could be considered feasible within the limb reconstruction population and possibly used for other patient groups. This data may enable us to more accurately predict length of stay in patients undergoing limb reconstruction and will provide a baseline for future comparisons of different interventions in this patient group

Introduction. Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS). Materials & Methods. The telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires. Results. Baseline data collected from April 2019 to April 2021 showed that our median LOS for patients undergoing external fixation was 6 days with 36% of patients being discharged at day 4 or earlier. After implementation of telemedicine, median LOS reduced to 4 days with 50% of patients leaving hospital in 4 days or less. Service user responses demonstrated that 100% felt that sufficient information was provided by the CNS team, a mean score of 8.4/10 was reported when asked how confident they were when adjusting the fixator. When asked how the service could be improved access to a recorded video was suggested. Conclusions. Initial fixator adjustment support via telemedicine is not appropriate for all of our patient group due to a lack of access or co-morbidities/ social issues that necessitate a prolonged hospital stay. However, this project has demonstrated that it has had positive long-term benefits within our service through reducing our median length of stay by 2 days without compromising patient satisfaction with their care

Aims. Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. Methods. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded. Results. A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection. Conclusion. Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay. Cite this article: Bone Jt Open 2021;2(8):655–660

Reduction of length of stay (LOS) without compromising quality of care is a trend observed in orthopaedic departments. To achieve this goal the pathway needs to be optimised. This requires team work than can be supported by e-health solutions. The objective of this study was to assess the impact of reduction in LOS on complications and readmissions in one hospital where accelerated discharge was introduced due to the pandemic. 317 patients with primary total hip and total knee replacements treated in the same hospital between October 2018 and February 2021 were included. The patients were divided in two groups: the pre-pandemic group and the pandemic group. The discharge criteria were: patient feels comfortable with going back home, patient has enough support at home, no wound leakage, and independence in activities of daily living. No face-to-face surgeon or nurse follow-up was planned. Patients’ progress was monitored via the mobile application. The patients received information, education materials, postoperative exercises and a coaching via secure chat. The length of stay (LOS) and complications were assessed through questions in the app and patients filled in standard PROMs preoperatively, at 6 weeks and 3 months. Before the pandemic, 64.8% of the patients spent 3 nights at hospital, whereas during the pandemic, 52.0% spent only 1 night. The median value changed from 3 days to 1 day. The complication rate before the pandemic of 15% dropped to 9 % during the pandemic. The readmission rate remained stable with 4% before the pandemic and 5 % during the pandemic. No difference were observed for PROMS between groups. The results of this study showed that after a hip and knee surgery, the shortening of the LOS from three to one night resulted in less complications and a stable rate of readmissions. These results are in line with literature data on enhanced recovery after hip and knee arthroplasty. The reduction of LOS for elective knee and hip arthroplasty during the pandemic period proved safe. The concept used in this study is transferable to other hospitals, and may have economic implications through reduced hospital costs

We examined the effect of age, gender, body mass index (BMI), medical co-morbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA). Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods. To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univariate and by Logistic regression for multivariate analysis. The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4. On univariate analysis age above 80 years, age between 70 and 79 years, Body Mass Index > 35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays. On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks. This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission

We examined the effect of age, gender, body mass index (BMI), medical comorbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA). Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods. To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univarate and by Logistic regression for multivariate analysis. The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4. On univarate analysis age above 80 years, age between 70 and 79 years, Body Mass Index > 35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays. On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks. This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission

Early mobilization within the first 12 hours (day zero) of total joint arthroplasty (TJA) has been shown to reduce length of stay (LoS) without risking clinical outcomes, patient safety or satisfaction. The purpose of this study was to investigate associations between the degree of mobilization on day zero (i.e., standing at the bedside versus walking in the hallway) and LoS in TJA patients. In addition, we investigated predictors of LoS and day zero mobilization. A retrospective cohort study was undertaken of the health records of patients in a community hospital setting who had an elective unilateral primary TJA between June 2015 and May 2017 and had mobilized on day zero. The total sample was 283 patients (184 TKA and 99 THA) across four mobilization categories: Sat on beside (n = 76), Stood by bed/marched in place (n = 83), Walked in the room (n = 79), and Walked in hall (n = 45). Analysis of variance found no significant group differences in age, ASA score, Charlson Comorbidity Index score, anesthesia, surgeon, procedure type, pain medication, and patient reported symptoms recorded by physiotherapists. Significantly more women were in the Sat group and significantly more men were in the Hall group (p < .001). Patient reported symptoms of nausea and drowsiness were significantly greater for the Sat group (p < .001). LoS was also significantly different across the groups. Post hoc Tukey comparisons found the Walked Hall group had significantly shorter LoS (M = 2.7 days) than the Sat group (M = 3.9, p < .001), Stood group (M = 3.4, p = .011), and the Walked Room group (M = 3.5, p = .004). A hierarchical regression was performed to determine predictors of LoS. Block 1 consisted of demographic, medical status, and patient reported symptoms as variables. Mobilization was entered in Block 2. The first model was significant (p < .001) and explained 24% of variance in LoS. The final model was also significant (p < .001), accounting for a total of 26% of the variance in LoS. Thus, block 2 (i.e., mobilization) accounted for a small but significant 2% incremental variance (p = .008) beyond the block 1 variables in the prediction of LoS. With mobilization added, only male gender (p = .002), lower BMI (p = .026), and lower ASA scores (p = .006) remained significant predictors of shorter LoS, and the predictive ability of several of the block 1 variables were reduced to non-significant levels. A simultaneous regression model was then used to predict degree of mobilization. The model accounted for 24% of the variance in mobilization (p < .001). Variables significantly associated with a greater degree of mobilization included: younger age, male gender, lower BMI, and fewer symptoms, namely nausea, numbness, lightheadedness, and drowsiness. This study found length of stay was shorter when patients mobilized farther on the day of surgery. Some factors predictive of mobilization may be modifiable. Focusing on symptom management could increase opportunities for farther mobilization on the day of surgery, and thus decrease length of stay

Aims. Around the world, the emergence of robotic technology has improved surgical precision and accuracy in total knee arthroplasty (TKA). This territory-wide study compares the results of various robotic TKA (R-TKA) systems with those of conventional TKA (C-TKA) and computer-navigated TKA (N-TKA). Methods. This is a retrospective study utilizing territory-wide data from the Clinical Data Analysis and Reporting System (CDARS). All patients who underwent primary TKA in all 47 public hospitals in Hong Kong between January 2021 and December 2023 were analyzed. Primary outcomes were the percentage use of various robotic and navigation platforms. Secondary outcomes were: 1) mean length of stay (LOS); 2) 30-day emergency department (ED) attendance rate; 3) 90-day ED attendance rate; 4) 90-day reoperation rate; 5) 90-day mortality rate; and 6) surgical time. Results. A total of 8,492 knees from 7,746 patients were included in the study. Overall robotic use had risen to 20.4% (2023 Q3 to Q4: 355/1,738) by the end of 2023, with Mako being the most popular at 10.3% (179/1,738). R-TKA had the shortest mean LOS compared with N-TKA and C-TKA (5.5 vs 6.3 and 7.1 days, respectively; p < 0.001). Only Mako (9.7%) demonstrated reduced 90-day ED attendance compared to C-TKA (13.1%; p = 0.009), Cori/Navio (15.0%; p = 0.005), and Rosa (16.4%; p < 0.001). No differences in 90-day reoperation rate and mortality were observed between all groups. Mean surgical times were longer in R-TKA groups by 20.6 minutes (p < 0.001). Conclusion. R-TKA use has increased in recent years, and has been shown to reduce hospital stay despite having a slightly longer surgical time, proving a promising candidate to alleviate the burden on healthcare systems. Individual differences between R-TKA systems contributed to variable clinical outcomes. Cite this article: Bone Jt Open 2024;6(1):12–20

Provision of prehabilitation prior to total knee arthroplasty (TKA) through a digital mobile application is a novel concept. Our research evaluates a resource effective and cost effective method of delivering prehabilitation. The primary aim of our research is to determine whether provision of prehabilitation through a mobile digital application impacts inpatient LOS after TKA. The secondary objective is to understand the effect of digital prehabilitation on hospital costs. An observational, retrospective analysis was performed on a consecutive case series of 64 patients who underwent TKA by a single surgeon over a 21 month period. Exercise provision varied from 3 months to 2 weeks prior to TKA. The outcomes of rehabilitation length of stay, total length of stay and total hospital costs were statistically significantly at p=0.5. The rehabilitation length of stay was 3.79 days in the experimental and 7.33 days in the control group (p = 0.045), the total length of stay was 12.00 days in the control and 8.04 days in the experimental group (p=0.03) and the total cost of the hospital stay was $6357.35AUD for the control and $4343.22AUD for the experimental group (p=0.029). Our research shows a cost saving with this intervention, as measured by a reduction in rehabilitation length of stay. To our knowledge, this is the first piece of research that analyses the impact of the use of a digital mobile application providing prehabilitation prior to TKA

Recent studies have described safe outcomes for short-stays in the hospital after total shoulder arthroplasty. The purpose of this study is to identify pre-operative and operative risk factors for hospital admissions exceeding 24 hours. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2016 for the current procedural terminology (CPT) billing code related to total shoulder arthroplasty. Patients were then grouped as either having a length of stay (LOS) equal to or less than 24 hours or greater than 24 hours. Patients admitted to the hospital prior to the day of surgery were excluded. Patient demographics, co-morbidities, and operative time were then analyzed as risk factors for a hospital stay exceeding 24 hours. Pre-operative co-morbidities included body mass index (BMI), diabetes, smoking, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, dialysis, chronic steroid or immunosuppressant use, bleeding disorders, and American Society of Anesthesiologists (ASA) Classification. Univariate and multivariate analyses were then performed to identify risk factors associated with 30-day readmission. 14,339 patients met inclusion criteria and 6,507 (45.3%) had a hospital LOS less than or equal to 24 hours. The mean length of hospitalization was 1.95 ± 1.88 days, the average age was 69 ± 9.7 years old, and 56.9% of the patients were female. Following a risk adjusted multivariate analysis, increasing age (odds ratio [OR], 1.03, 95% confidence interval [CI], 1.02–1.03), ASA classification (OR, 1.50, 95% CI, 1.41–1.60), diabetes (OR, 1.69, 95% CI, 1.43–1.99), COPD (OR, 1.35, 95% CI, 1.16–1.57), CHF (OR, 2.67, 95% CI, 1.34–5.33), dialysis (OR, 2.47, 95% CI, 1.28, 4.77), history of a bleeding disorder (OR, 1.50, 95% CI, 1.20–1.88), or increasing operative time (OR, 1.01, 95% CI, 1.01–1.01) were identified as independent risk factors for hospital lengths of stay exceeding 24 hours. Male gender was identified as a protective factor for prolonged hospitalization (OR, 0.50, 95% CI, 0.46–0.53). This study identifies patient demographics, co-morbidities, and operative-relative risk factors that are associated with increased risk for a prolonged hospitalization following total shoulder arthroplasty. Female gender, increasing age, ASA classification, operative time, or a history of diabetes, COPD, CHF, or history of a bleeding disorder are risk factors hospitalizations exceeding 24 hours

This study was designed to compare length of hospital stay, and 30-day major and minor complications between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal or epidural anesthesia with or without regional nerve blocks. Patients 18 years and older undergoing TKA between the years of 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Patients with “primary anesthesia technique” codes for either spinal or epidural anesthesia along with “other anesthesia technique” codes for regional anesthesia were assumed to have been given a regional nerve block. Chi square tests, and analysis of variance were utilized to evaluate unadjusted differences in demographics and outcomes between anesthesia types. Multivariable regression was utilized to compare outcomes (length of stay and complications) between anesthesia types, while adjusting for age, American Society of Anesthesiologist (ASA) class, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status. A total of 214,665 TKA patients were identified (average age 67 ± 10 years). Of these, 257 (0.12%) underwent epidural anesthesia with a nerve block (EB), while 2,318 (1.08%) underwent epidural anesthesia with no block (E), 14,468 (1.08%) underwent spinal anesthesia with a block (SB), and 85,243 (39.7%) underwent spinal anesthesia with no block (S), and 112,377 (52.4%) underwent general anesthesia (G). The unadjusted length of stay (LOS) was significantly longer in the E group (3.67 ± 5 days) compared to the G group (3.1 ± 3.9 days), while the unadjusted LOS was significantly shorter in the EB group (2.6 ± 1.2), and both SB and S groups (2.6 ± 3 and 2.9 ± 3, respectively), compared to the G group p < 0 .001. Following covariable adjustment, anesthesia type remained an independent predictor of length of stay. Compared to the G group, patients in the E group stayed 0.56 days longer (95% Confidence interval [95%CI] 0.42 – 0.71 days), while patients in the SB were discharged 0.28 days (95%CI 0.21 – 0.35 days) earlier, and those in the S group were discharged 0.06 days earlier (95%CI 0.02–0.09), (p < 0 .0001). While the unadjusted rates of major complications were not significantly different between groups, the unadjusted rates of minor complications were higher in the E, EB, and G groups compared to the S and SB groups. Following covariable adjustment, there were no differences between groups in the risk of minor complications. In conclusion, these data indicate that anesthesia type following TKA is associated with length of hospital stay, but not with 30-day complications. After adjusting for relevant covariables, patients who received epidural anesthesia without a nerve block for TKA were discharged later, while patients who received spinal anesthesia, both with and without a nerve block for TKA were discharged earlier, compared to patients who received general anesthesia for TKA

Background. The ability to identify those at risk for longer inpatient stay helps providers with postoperative planning and patient expectations. Decreasing length of stay in the future will be determined by appropriate patient selection, risk stratification, and pre-operative patient optimization. The purpose of this study was to identify factors that place patients at risk for extended postoperative lengths of stay. Methods. The prospective study cohort included 2009 primary total knee arthroplasty (TKA) patients and 905 total hip arthroplasty (THA) patients. Patient comorbidities were prospectively identified and the length of stay for each patient was tracked following a primary arthroplasty. Statistical analysis was performed to correlate which comorbidities were associated with longer inpatient stays. Results. In the TKA population, gender, smoking status, venous thromboembolism history, body mass index and diabetes status were not found to be a significant predictors for length of stay. Age was found to be a factor in univariate regression testing (P<0.001). In the THA population, univariate testing showed female gender (P<0.001), smoking status (P=0.002), and age (p<0.001) to be factors, but like the TKA population venous thromboembolism history or diabetes status were not significant. In THA multivariate analysis, age (p<0.001) and female gender (p=0.018) continued to be factors, but smoking was determined to be a confounding variable. Conclusions. Age and gender were associated with a longer length of stay after THA, whereas only age was a significant factor after TKA. Development of age adjusted LOS models may help aid patient expectations and risk management

Introduction. Provision of prehabilitation prior to total knee arthroplasty (TKA) through a digital mobile application is a novel concept. The primary aim of our research is to determine whether provision of prehabilitation through a mobile digital application impacts length of stay (LOS), requirement for inpatient rehabilitation and hospital-associated costs after TKA. Our study hypothesis is that a mobile digital application provides a low resource, cost effective method of delivering prehabilitation prior to TKA. Methods. An observational, retrospective analysis was performed on a consecutive case series of 64 patients who underwent TKA by a single surgeon over a 21-month period. Pre operative Knee Osteoarthritis Outcome Score (KOOS) Patient Reported Outcome Measures (PROMs) were collected on all patients. The first group of patients (control) did not undergo prehabilitation, the subsequent group of patients (experimental) were offered prehabilitation through a mobile application called PhysiTrack. The experimental group were provided with progressive quadriceps and hamstring strengthening exercises, and calf and hamstring stretches. Exercises were automatically progressed after 2 weeks unless the patient requested otherwise or a physiotherapist clinically intervened. The non-compliance rate was 33% (n=11), after removing these patients from the analysis, 22 patients remained and these were age matched to 22 patients from the control group. Aside from the access to prehabilitation, all patients underwent TKA using identical surgical technique and peri-operative care regime. Length of stay data for inpatient care and rehabilitation were captured for all patients. Cost was calculated using the inpatient and rehabilitation costs provided by the hospital. Results. 44 patients were included in our final analysis. Pre operative KOOS were collected for all of the experimental group and 18 (81%) of control group. These subscores were not statistically different (p>0.05) reflecting pre operative equivalence. The average inpatient length of stay was statistically different, being 5.04 days for the control group and 4.31 days for the experimental group (p=0.01). The decision for ongoing inpatient rehabilitation (after the immediate post-operative inpatient period) was not statistically different between the groups (chi-quared p=0.07). Rehabilitation length of stay was 9.12 days in the experimental and 10.85 days in the control group (p = 0.25). The remaining outcomes were statistically significant with total length of stay 11.95 days in the control and 7.63 days in the experimental group (p=0.01) and the total cost of the hospital stay $6362.55AUD for the control and $4145.17AUD for the experimental group (p=0.01). This represents an average saving $2217.38 per patient who participated in prehabiliation prior to surgery. Conclusions. Our research shows a significant cost saving with this intervention, as measured by reduction in total length of stay in patients undergoing prehabilitation using PhysiTrack. To our knowledge, this is the first study that analyses the impact of a mobile application providing prehabilitation prior to TKA. Further work is required to determine the effect in a larger, randomised cohort of patients. Future studies should also be directed towards assessing the utility of digital prehabilitation on a per patient basis prior to total knee arthroplasty