Abstract
Background
Despite a sevenfold decline in the number of postoperative nights (21–3) after a total knee arthroplasty (TKA) over the last four decades, predictors of length of stay (LOS) are not fully understood. We attempted to ascertain these factors by analyzing a large cohort of patients.
Methods
Prospectively collected data between January 2016 and March 2017 were retrospectively analyzed at our institute. Charts of 1663 consecutive, simple primary unilateral and bilateral TKAs were reviewed for the LOS excluding staggered bilateral, complex primary and revision knees. Statistical analysis: Preoperative variables [demographics, cash/credit status, historical, clinical, laboratory findings, Knee Society Function Scores and Oxford Knee Scores (OKSs)] were scrutinized by multivariate regression to identify significant factors affecting LOS and formulate model equations for patients and health caregivers. Results were incorporated into an iOS application, which was tested for accuracy.
Results
Among 1524 unilateral and 139 bilateral TKAs, mean LOS was 4.4 and 5.2 days, respectively. Five factors, namely insurance, flexion/hyperextension deformity, preoperative OKS and a rheumatoid etiology, were significantly associated with prolonged LOS in unilateral knees. The impact of these independent variables on LOS could be calculated by:
For bilateral cases, the only significant variable extending LOS was a low preoperative OKS and the equation is given as follows:
The iOS-app-predicted LOS and actual LOS were similar (p > 0.05) for 115 prospectively operated knees.
Conclusion
Poor preoperative OKS, rheumatoid etiology, flexion and hyperextension deformity and delays in insurance affected unilateral TKR LOS, while poor preoperative OKS alone affected LOS in bilateral cases.
Similar content being viewed by others
References
Cross M, Smith E, Hoy D et al (2014) The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 73(7):1323–1330. https://doi.org/10.1136/annrheumdis-2013-204763
Jauregui JJ, Cherian JJ, Pierce TP, Beaver WB, Issa K, Mont MA (2015) Long-term survivorship and clinical outcomes following total knee arthroplasty. J Arthroplasty 30(12):2164–2166. https://doi.org/10.1016/j.arth.2015.05.052
Ahmed I, Salmon LJ, Waller A, Watanabe H, Roe JP, Pinczewski LA (2016) Total knee arthroplasty with an oxidised zirconium femoral component: ten-year survivorship analysis. Bone Joint J 98-B(1):58–64. https://doi.org/10.1302/0301-620x.98b1.36314
Mistry JB, Elmallah RK, Chughtai M, Oktem M, Harwin SF, Mont MA (2016) Long-term survivorship and clinical outcomes of a single radius total knee arthroplasty. Surg Technol Int 28:247–251
Hussain N, Chien T, Hussain F et al (2013) Simultaneous versus staged bilateral total knee arthroplasty: a meta-analysis evaluating mortality, peri-operative complications and infection rates. HSS J 9(1):50–59. https://doi.org/10.1007/s11420-012-9315-7
Sliva CD, Callaghan JJ, Goetz DD, Taylor SG (2005) Staggered bilateral total knee arthroplasty performed four to seven days apart during a single hospitalization. J Bone Joint Surg Am 87(3):508–513
Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89-A:780–785
Coventry M, Beckenbaugh R, Nolan D, Ilstrup D (1974) 2,012 total hip arthroplasties: a study of post-operative course and early complications. J Bone Joint Surg 56A:273
Husted H, Holm G, Jacobsen S (2008) Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 79(2):168–173. https://doi.org/10.1080/17453670710014941
Halawi MJ, Vovos TJ, Green CL, Wellman SS, Attarian DE, Bolognesi MP (2015) Preoperative predictors of extended hospital length of stay following total knee arthroplasty. J Arthroplasty 30(3):361–364. https://doi.org/10.1016/j.arth.2014.10.025
https://medlineplus.gov/ency/patientinstructions/000665.htm. Accessed 29 Apr 2019
Lavernia CJ, Guzman JF (1995) Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty 10(2):133–140
Styron JF, Koroukian SM, Klika AK, Barsoum WK (2011) Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty. J Arthroplasty 26(8):1418–1426.e1-2. https://doi.org/10.1016/j.arth.2010.11.008
Forrest G, Fuchs M, Gutierrez A, Girardy J (1998) Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty. J Arthroplasty 13(2):186–190
Raut S, Mertes SC, Muniz-Terrera G, Khanduja V (2012) Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop 36(8):1601–1608. https://doi.org/10.1007/s00264-012-1538-1
Smith ID, Elton R, Ballantyne JA, Brenkel IJ (2008) Pre-operative predictors of the length of hospital stay in total knee replacement. J Bone Joint Surg Br 90(11):1435–1440. https://doi.org/10.1302/0301-620X.90B11.20687
Ong PH, Pua YH (2013) A prediction model for length of stay after total and unicompartmental knee replacement. Bone Joint J 95-B(11):1490–1496. https://doi.org/10.1302/0301-620x.95b11.31193
Raphael M, Jaeger M, van Vlymen J (2011) Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth 58(10):902–910. https://doi.org/10.1007/s12630-011-9565-8
Shin YH, Kim MH, Ko JS, Park JA (2010) The safety of simultaneous bilateral versus unilateral total knee arthroplasty: the experience in a Korean hospital. Singap Med J 51(1):44–49
Bohm ER, Molodianovitsh K, Dragan A et al (2016) Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthop 87(Suppl. 1):24–30. https://doi.org/10.1080/17453674.2016.1181817
Lane GJ, Hozack WJ, Shah S et al (1997) Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analysis. Clin Orthop Relat Res 345:106–112
Koo K, Silva A, Chong HC et al (2016) Genu recurvatum versus fixed flexion after total knee arthroplasty. Clin Orthop Surg 8(3):249–253. https://doi.org/10.4055/cios.2016.8.3.249
Sodhi N, Patel YH, George J et al (2018) Operative time, length of stay, short-term readmission, and complications after hinged primary total knee arthroplasty: a propensity score matched analysis. J Knee Surg 31(10):940–945. https://doi.org/10.1055/s-0038-1668580
Zhang S, Huang Q, Xie J, Xu B, Cao G, Pei F (2018) Factors influencing postoperative length of stay in an enhanced recovery after surgery program for primary total knee arthroplasty. J Orthop Surg Res 13(1):29. https://doi.org/10.1186/s13018-018-0729-x
Liao CY, Chan HT, Chao E, Yang CM, Lu TC (2015) Comparison of total hip and knee joint replacement in patients with rheumatoid arthritis and osteoarthritis: a nationwide, population-based study. Singap Med J 56(1):58–64
Escalante A, Beardmore TD (1997) Predicting length of stay after hip or knee replacement for rheumatoid arthritis. J Rheumatol 24(1):146–152
Clement ND, Macdonald D, Burnett R (2013) Predicting patient satisfaction using the Oxford knee score: where do we draw the line? Arch Orthop Trauma Surg 133(5):689–694. https://doi.org/10.1007/s00402-013-1728-3
Smith AL, Kulhari A, Wolfram JA, Furlan A (2017) Impact of insurance precertification on discharge of stroke patients to acute rehabilitation or skilled nursing facility. J Stroke Cerebrovasc Dis 26(4):711–716. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.12.037
Mehta S, Nair J, Rao S, Shukla K (2015) Role of discharge planning and other determinants in total discharge time at a large tertiary care hospital. CHRISMED J Health Res 2:46–50. https://doi.org/10.4103/2348-3334.149345
Englum BR, Hui X, Zogg CK et al (2016) Association between insurance status and hospital length of stay following trauma. Am Surg 82(3):281–288
Husted H, Hansen HC, Holm G et al (2010) What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg 130(2):263–268. https://doi.org/10.1007/s00402-009-0940-7
Cunic D, Lacombe S, Mohajer K, Grant H, Wood G (2014) Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS. Can J Surg 57(6):391–397
Carter EM, Potts HW (2014) Predicting length of stay from an electronic patient record system: a primary total knee replacement example. BMC Med Inform Decis Mak 4(14):26. https://doi.org/10.1186/1472-6947-14-26
Acknowledgements
The authors wish to thank and acknowledge the contributions of Mr. Gautam Goud, our statistician, toward the statistical computation of our data and its analysis. No funds or grants were received toward the conduct of this research.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Khanna, V., Gurava Reddy, A.V., Daultani, D. et al. When can I go home after my knee replacement? Factors affecting the duration of in-hospital stay after knee replacement. Eur J Orthop Surg Traumatol 29, 1719–1728 (2019). https://doi.org/10.1007/s00590-019-02485-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-019-02485-5