Keeping you up-to-date on recent headlines in orthopedic healthcare:

Outpatient total and unicompartmental knee replacement possible, study finds... Outpatient knee replacement has been made possible with the advent of newer anesthetics and rehabilitation protocols but some concerns – such as readmission and ER visits – still exist, according to a recently presented study. "The length of stay with knee replacement, whether it is uni or totals, has clearly decreased in the last few decades," Richard Berger, MD, said at the recent American Academy of Orthopaedic Surgeons (Rosemont, Illinois) annual meeting. "In fact, 6 years ago we started doing outpatient total knee and unicompartmental knee arthroplasty... though these were on highly selective patients. The questions were: Can outpatient knee replacement be done safely in unselected patients? If so, what problems would occur?" Berger's study assessed the feasibility and perioperative complications following outpatient total knee and unicompartmental knee arthroplasty (UKA). To accomplish the goal of outpatient total knee arthroplasty (TKA), a minimally invasive surgical technique, improved perioperative anesthesia and an expedited rehabilitation protocol were developed. The study looked at 121 consecutive patients who had primary knee replacement completed by noon, with 10 patients refusing participation. The remaining 111 – 25 UKA and 86 TKA – followed a comprehensive perioperative clinical pathway, including education, regional anesthesia, preemptive oral analgesia, preemptive antiemetics and a rapid rehabilitation protocol. Of the 111 patients, 104 (94%) were discharged on the day of the surgery. Four readmissions and one ER visit without readmission occurred within the first week following surgery. In the first month following surgery, four additional readmissions and one additional ER visit without readmission occurred. All readmissions were in the immediate perioperative period, according to the study, and in patients who had undergone primary TKA. Berger said the lack of impact certain factors had on the results of the study was surprising. "Ninety-four percent of the patients were able to go home the day of surgery," he said. "Surprisingly, this was not related to age, weight, gender or BMI." Although there are unaccounted issues involving an immediate or delayed need for additional medical care, Berger said the results are impressive and may even improve with more stringent exclusion criteria.

Joint replacement patients with diabetes greatly benefit from controlled glucose ... Diabetics undergoing total joint replacement often are at a higher risk of experiencing complications after surgery due to various pre-existing health conditions. According to a new study published in the July 2009 issue of The Journal of Bone and Joint Surgery (JBJS), those complications are less likely to occur when a diabetic patient has glucose levels under control. "We found that controlled glucose levels really do make a difference for the patient," said study co-author Milford Marchant Jr., MD, an orthopedic surgeon who conducted the study with colleagues of the Adult Reconstruction Section at Duke University Medical Center (Durham, North Carolina).The study found that patients with uncontrolled glucose levels were:

  • More than 3 times as likely to experience a stroke or death after joint replacement surgery; and
  • About twice as likely to experience post-operative bleeding and infection.
  • Marchant and his colleagues reviewed data from a national healthcare database looking at more than one million patients who had total joint replacement surgery from 1988 to 2005. They compared surgical outcomes in patients with uncontrolled glucose levels to those who had controlled glucose levels and those patients who did not have diabetes. "It did not matter if the patient had Type I or Type II diabetes," explains Dr. Marchant. "Regardless of diabetes type, we found that patients had fewer complications after surgery if their glucose level was controlled before, during and after surgery." Diabetic patients with uncontrolled glucose were more likely to experience surgical complications, infection, blood transfusions and longer hospitals stays. About 8% of patients undergoing total hip and knee replacement in the U.S. have diabetes.

    Emerging techniques put a new twist on ankle repair... People with ankle injuries who do not respond successfully to initial treatment may have a second chance at recovery, thanks to two new procedures developed to restore the injured area, according to a study published in the July 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). The study reviews emerging techniques that have proven successful in treating injuries to the talus, the small bone, which is located between the heel bone and the lower bones of the leg. The talus helps form the ankle joint.

    Although most injuries to the talus can be successfully treated using traditional "first-line" therapies involving removal of dead tissue (called "debridement") and drilling, about one-fifth to one-quarter of people with ankle injuries need additional "second-line" restorative treatment to heal successfully, said lead author Matthew Mitchell, MD, an orthopedic surgeon in private practice in Casper, Wyoming. The two new techniques rely on cells grown in a lab, and eliminate the need for ostetomy (cutting the bone of the tibia) in some cases, he said. Autologous chondorcyte implantation, or ACI, involves removing cartilage cells from the knee or the ankle and growing them in a lab. Once grown, the cartilage is transplanted to the talus. ACI usually involves an ostetomy in order to implant the cells. In matrix-induced autologous chondrocyte implantation, or MACI, cells are grown on a special backing material, or "matrix," and then transplanted to the talus. In the authors' experience, an osteotomy is not necessary to implant the cells. Of these two techniques, the newer MACI technique may offer the most benefits to the patient, according to Mitchell. "Both ACI and MACI show a lot of promise, but I think the advantage of MACI is that an osteotomy is not necessary in order to successfully implant the matrix," he said. "You only need to make an incision to place the graft, which decreases the morbidity of the procedure quite a bit."

    Using clinical pathways in joint replacement treatment... Clinical pathways have been used in surgeries since the 1980s, but their nature and usefulness are still subjects of much debate, especially as procedures such as hip and knee joint replacement represent a significant cost to hospitals. Now authors publishing in the open access journal BMC Medicine have concluded that using clinical pathways can effectively improve the quality of the care provided to patients undergoing joint replacement. A research team from the University of Eastern Piedmont, the Catholic University Leuven, the University Politecnica delle Marche and the Sainte Rita Hospital Trust searched four databases (Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials) using relevant medical subject headings. The authors compared trials that contrasted the clinical pathways care with standard medical care while analyzing at least one of the four possible clinical outcomes of postoperative complications, discharge to home, length of in-hospital stay (LOS) and direct costs. The meta-analysis, covering 6,316 patients, showed that patients in the clinical pathways group had significantly lower levels of postoperative complications and significantly shorter hospital stays, which greatly contributed to lower hospital costs. The authors believe that these positive findings are a consequence of the care being better organized. Inappropriate care lengthens hospital stays and increases the risk of complications; clinical pathways have been shown to prevent inappropriate care and, thus, the cost to the hospital.

    — Compiled by Holland Johnson, MDD