Goodson KM, Kee JR, Edwards PK, Novack AJ, Stambough JB, Siegel ER, Barnes CL, Mears SC.
J Arthroplasty 2020 Mar;35(3S):S63-S68. doi: 10.1016/j.arth.2019.10.056
Summary by Mohammad S Abdelaal MD, MSc
While concerted national efforts have been made to streamline primary hip and knee arthroplasty to short-stay episodes of care as a form of cost containment and value-based care [1, 2], little formal effort has been made to decrease the length of stay in PJI patients. Following surgical management for PJI, patients are routinely admitted to the hospital for monitored administration of IV pathogen-specific antibiotic which is adjusted based on the finalized culture results and respective in vitro susceptibilities. This process frequently takes 5 to 7 days [3,4] subjecting patients to a prolonged hospital stay, and adding to the physical, psychological, and economic burden associated with PJI management [5-7].
In this study, Goodson et al developed a fast-track PJI care system using an infectious disease physician to coordinate the treatment of PJI patients with the TJA team. They retrospectively reviewed 78 fast-track patients who were discharged once ready for mobilization before finalization of the culture results. This was compared to control cohort of 67 patients with a standard discharge after all culture results and susceptibilities were finalized. They found that LOS was significantly lower (3.8 vs 5.7 d, p=.012) in the fast track group, with no events of antibiotic mismatch compared to the control group. No significant differences were noted comparing 90-day complications, reimplantation rate, or 12-month reimplantation survival rates between both groups. Based on these findings, they concluded that streamlining care pathway in treatment of PJI is safe and can significantly shorten hospital LOS and help to decrease the overall healthcare costs associated with treating PJI.
Acknowledged limitations of the study included small sample size which was attributed to the relative recent implementation of the program, low 12-month follow up rates (only 53%), variability of insurance approvals of home administered antibiotics and, finally, limited true secondary outcomes as some events may take place in other institutions (e.g complications and readmission).
- Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “Outpatient Arthroplasty Risk Assessment Score.”. J Arthroplasty 2017;32:2325e31. https://doi.org/10.1016/j.arth.2017.03.004.
- Edwards PK, Milles JL, Stambough JB, Barnes CL, Mears SC. Inpatient versus outpatient total knee arthroplasty. J Knee Surg 2019;32:730e5. https:// doi.org/10.1055/s-0039-1683935.
- Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases Society of America. Clin Infect Dis 2013;56:e1e25. https://doi.org/10.1093/cid/cis803.
- Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of peri- prosthetic joint infection in the United States. J Arthroplasty 2012;27: 61e65.e1. https://doi.org/10.1016/j.arth.2012.02.022.
- Kheir MM, Tan TL, Ackerman CT, Modi R, Foltz C, Parvizi J. Culturing peri- prosthetic joint infection: number of samples, growth duration, and organ- isms. J Arthroplasty 2018 Nov;33:3531e3536.e1. https://doi.org/10.1016/ j.arth.2018.06.018.
- Klouche S, Sariali E, Mamoudy P. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res 2010;96: 124e32. https://doi.org/10.1016/j.otsr.2009.11.004. Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA.
- Current epidemiology of revision total knee arthroplasty in the United States. J Arthroplasty 2017;32:2663e8. https://doi.org/10.1016/j.arth.20 17.03.066.