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Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge ( n  = 378,771) and nonhome discharge ( n  = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients., Competing Interests: N.S.P. disclosed serving as a board or committee member for the American Association of Hip and Knee Surgeons, International Society for Cell and Gene Therapy, and Orthopaedic Research Society, serving on the editorial boards for the Journal of Hip Surgery and Journal of Knee Surgery, serving as a paid consultant for Regeneron and Stryker, and receiving research support from Osteal Therapeutics, Signature Orthopaedics, RegenLab, and Zimmer.R.M.M. reports personal fees and grants from Striker, grants from Zimmer, other from American Academy of Hip and Knee Surgeons, outside the submitted work.V.E.K. reports personal fees royalties, and grants from Striker, serving on the editorial boards for the Journal of Arthroplasty,All other authors have no disclosures., (Thieme. All rights reserved.)

In staged bilateral total knee arthroplasty (BTKA), the intersurgical time is yet to be determined. This study aimed to (1) test for differences in in-hospital metrics between the index and contralateral TKA and (2) determine the safest intersurgical time interval to minimize adverse outcomes after the contralateral surgery. The National Readmissions Database was queried for patients who received staged BTKA (2016-2017). A total of 20,279 patients were included. Demographics, comorbidities, baseline determinants, and intersurgical time between index and contralateral TKAs (≤ 3 month, 4-6 months, 7-9 months, and 10-12 months intervals) were captured. Outcomes included healthcare utilization (length of stay [LOS] and nonhome discharge), in-hospital costs, and in-hospital complications. Outcomes were compared between index versus contralateral surgeries and among contralateral surgeries of various intersurgical intervals. Contralateral surgeries had shorter LOS (2.2 ± 1.9 vs. 2.4 ± 2.0 days; p  < 0.001), lower nonhome discharge ( n  = 2692[13.2%] vs. n  = 2963[14.7%]; p  = 0.001), and in-hospital costs ($16,476 ± $7,404 vs. 16,774 ± $9,621; p  < 0.001), but similar rates of nonmechanical ( p  = 0.40) complications compared with index TKA. Multivariable regression demonstrated that intersurgical time was not associated with nonmechanical complications or transfusion, or 30-day readmission ( p  > 0.05, each). Compared with the less than or equal to 3-month interval, the 4 to 6-month interval exhibited highest odds ratio (OR) of any infection (OR: 1.81; 95% confidence interval [CI]: [1.13-2.88]; p  = 0.013), urinary tract infection (OR:1.81, 95%CI: [1.13-2.90]; p  = 0.014), and any-cardiac complications (OR:1.17; 95%CI: [1.01-1.35]; p  = 0.037). Patients in the 10-12-month cohort had lowest odds of posthemorrhagic anemia (OR: 0.84; 95% CI: [0.72-0.98]; p  = 0.03). Overall, the second surgery of a staged BTKA has lower healthcare utilization despite similar complication rates. While patients in the 10 to 12-month intersurgical interval had the most favorable overall safety profile, no single interval exhibited consistently lower complications for all measured outcomes. Special care pathways should be optimized to care for patients undergoing staged BTKA., Competing Interests: None declared., (Thieme. All rights reserved.)

Mortality data following primary total knee arthroplasty (TKA) beyond 1-year postoperative time period is sparse. This systematic review and meta-analysis aimed to: (1) estimate contemporary mortality rates at 30 days, 90 days, 1 year, 5 years, and 10 years following primary TKA; and (2) identify risk factors and causes of mortality following TKA. PubMed, MEDLINE, Cochrane, EBSCO host, and Google Scholar databases were queried from January 1, 2011 to October 30, 2021 for all studies reporting mortality rates following primary TKA. A meta-analysis of proportions was conducted using a random-effects model to ascertain pooled mortality rates (95% confidence interval [CI]). Meta-regression was utilized to account for confounding effects on mortality rates due to the study's country of origin, median date of study data, average patient age, and patient gender ratios, with a level of significance maintained at p -value <0.05. A total of 44 articles were included in quantitative synthesis. The pooled 30-day mortality rate was 0.14% (95% CI:0.05-0.22%; n  = 1,817,647). The pooled 90-day mortality rate was 0.35% (95% CI:0.0.28-0.43%; n  = 1,641,974). The pooled 1-year mortality rate was 1.1% (95% CI:0.71-1.49%; n  = 1,178,698). The pooled 5-year mortality rate was 5.38% (95% CI:4.35-6.42%; n  = 597,041). The pooled 10-year mortality rate was 10.18% (95% CI:7.78-12.64%; n  = 815,901). Our 30-day mortality rate was lower than previously reported. The most common causes of death at all time points were due to cardiac disease, cerebrovascular disease, and malignancy. Obesity demonstrated mixed effects on long-term mortality rates. Overall mortality rates of TKA remain low worldwide at all time points and immediate postoperative mortality rates continue to fall. Compared to symptomatic knee osteoarthritic patients reported in the literature, TKA patients qualitatively exhibited lower mortality rates, which may support the value of TKA in improving quality of life without associated excess mortality. Future long-term mortality studies should be conducted to account for geographical variability in mortality rates and further elucidate modifiable risk factors associated with mortality among TKA patients., Competing Interests: N.S.P. has the following disclosures not related to the present study: American Association of Hip and Knee Surgeons: Board or committee member ISCT: Board or committee member Journal of Hip Surgery: Editorial or governing board Journal of Knee Surgery: Editorial or governing board Orthopaedic Research Society: Board or committee member Regeneron: Paid consultant RegenLab: Research support Stryker: Paid consultant Zimmer: Research support., (Thieme. All rights reserved.)

Venous thromboembolism (VTE) is a relatively common complication among patients undergoing primary total knee arthroplasty (TKA). This complication occurs in a spectrum of severity ranging from an incidental finding to serious readmission-requiring events. To date, the risk factors of serious VTE that require readmission have not been characterized. This study examines the patient and hospital characteristics associated with readmission for serious VTE after TKA. The National Readmission Database (NRD) from the Agency of Healthcare Research and Quality (AHRQ) was queried for patients who underwent primary TKA from January 2016-December 2018. The study population consisted of patients who were readmitted within 90 days following primary TKA with a primary diagnosis of VTE. Multivariable regression models were constructed to evaluate patient characteristics (age, sex, insurance, elective nature of procedure, hospital characteristics, discharge status, income, and comorbidities) associated with higher risk of developing readmission-requiring VTE. Readmission rates for VTE exhibited a higher incidence in patients older than 61 (compared with 40 and under), males (OR:1.08, 95%CI [1.03-1.14]), patients with nonelective procedures (OR:20.21, 95% CI [19.16-21.32]), patients at large hospitals(OR:1.17, 95% CI [1.09-1.25]), patients at private hospitals (OR:1.19, 95% CI [1.09-1.29]), and patients with non-home discharge statuses. Comorbidities of paralysis (OR:1.52, 95% CI [1.19-1.94]), neurological disorders (OR:1.12, 95% CI [1.02-1.23]), metastatic cancer (OR:1.48, 95% CI [1.01-2.17]), obesity (OR:1.11, 95% CI [1.06-1.17]), fluid and electrolyte imbalance (OR:1.28, 95% CI [1.18-1.38]), blood loss anemia (OR:1.29, 95% CI [1.02-1.64]), and iron deficiency anemia (OR:1.24, 95 % CI [1.15-1.33]) increased risk of VTE. Certain comorbidities requiring chronic anticoagulation were associated with lower risk of VTE. Insurance status and patient income did not exhibit any correlation with VTE incidence. Patient characteristics of male sex, age > 61, and baseline comorbidities (paralysis, neurological disorders, metastatic cancer, obesity, fluid and electrolyte imbalance, and blood loss/iron deficiency anemia) were at an increased risk of developing serious VTE. Patients without continued supervision at their discharge environment were at higher risk of developing serious VTE. Extra prophylaxis and special protocols may be warranted in these patients to prevent VTE complications., Competing Interests: The following authors have disclosures that are not related to the topic of the study at hand:V.E.K. Journal of Arthroplasty: Editorial or governing board; Publishing royalties, financial or material support.Stryker: IP royalties; Paid consultant; Stock or stock Options.N.S.P. American Association of Hip and Knee Surgeons: Board or committee member.ISCT: Board or committee member.Journal of Hip Surgery: Editorial or governing boardJournal of Knee Surgery: Editorial or governing boardOrthopaedic Research Society: Board or committee memberRegeneron: Paid consultantRegenLab: Research supportStryker: Paid consultant Zimmer: Research supportC.R., A.K.E., T.P., X.P., G.Z., and S.K. have nothing to disclose., (Thieme. All rights reserved.)