No abstract

Introduction:Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.Methods:In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.Results:In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).Conclusions:Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

Background: Meniscus root tears lead to de-tensioning of the meniscus, increased contact forces, and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear. Purpose: To compare the clinical outcomes of patients with moderate knee osteoarthritis who underwent an all-inside meniscus root repair technique versus nonoperative management for either medial or lateral meniscus root tears. Study Design: Cohort study; Level of evidence, 2. Methods: Patients with a diagnosed posterior meniscus root tear who underwent arthroscopic repair (AR: 30 knees) or nonoperative treatment with observation (O: 18 knees) were followed for a minimum of 2 years (mean follow-up, 4.4 years). The arthroscopic repair included all-inside sutures to reduce the root back to its remnant (reduction sutures), thereby re-tensioning the meniscus, and 1 mattress suture to strengthen the repair by reapproximating the construct to the posterior capsule. The data collected included the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and Veterans RAND 12-Item Health Survey (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and conversion to total knee arthroplasty (TKA). Results: Medial meniscus root tears comprised 80.0% of the AR group and 77.8% of the O group. The average Kellgren-Lawrence grade was 2 in both groups. The baseline scores for the KOOS Symptoms subscale were lower for AR (50.2 ± 19.3) than for O (66.5 ± 16.1) ( P = .003), as were the KOOS Knee-Related Quality of Life scores (AR, 26.7 ± 16.1; O, 39.6 ± 22.1) ( P = .046). No differences were found between groups for the absolute values at follow-up except that follow-up Tegner scores were lower in the O group than in the AR group ( P = .004). Significant improvements were seen in the AR group from baseline to ultimate follow-up in average KOOS subscale scores ( P < .001), Lysholm scores ( P < .001), Tegner scores ( P = .0002), and VR-12 PCS scores ( P < .001), whereas the O group had a significant improvement only in average KOOS Pain ( P = .003), KOOS Function in Daily Living ( P = .006), and VR-12 PCS ( P = .038) scores. Compared with the O group, the AR group had a significantly larger improvement from baseline to follow-up in average KOOS Pain ( P = .009), KOOS Symptoms ( P = .029), and Lysholm scores ( P = .016). During follow-up, 3.3% of the AR group underwent a TKA compared with 33.3% of the O group ( P = .008). The hazard ratio of TKA conversion was 93.2% lower for the AR group compared with the O group ( P = .013). Conclusion: All-inside medial or lateral meniscus root repair showed improved functional outcomes and decreased TKA conversion rates compared with nonoperative treatment and may be considered as a treatment option for the management of meniscus root tears in older patients with moderate osteoarthritis.