What is Associated with the Greatest Effect on Lengths of Stay after Total Knee Arthroplasty: The Hospital, the Surgeon, or the Patient

Journal of Clinical Orthopaedics | Vol 8 | Issue 2 |  Jul-Dec 2023 | page: 07-11 | Max Willinger, Peter Gold, Luke Garbarino, Hiba Anis, Nipun Sodhi, Jonathan R Danoff

DOI: https://doi.org/10.13107/jcorth.2023.v08i02.580

Author: Max Willinger [1], Peter Gold [1], Luke Garbarino [1], Hiba Anis [2], Nipun Sodhi [1], Jonathan R Danoff [3]

[1] Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA,
[2] Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA,
[3] Department of Orthopedic Surgery, North Shore University Hospital, Manhasset, New York, USA.

Address of Correspondence
Dr. Max Willinger,
Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
E-mail: max.willinger1@gmail.com


Introduction: Patient-, hospital-, and surgeon-related factors are each associated with the variable nature of length of stay (LOS) after total knee arthroplasty (TKA). However, there is a paucity of literature regarding these intertwined relationships. This study aimed to determine if the hospital, the surgeon, or the patient has the greatest association with LOS after TKA.
Materials and Methods: A total of 11,402 patients were identified from a multicenter prospectively collected institutional database between January 01, 2017, and April 01, 2019. Surgeons and hospitals were subdivided into three groups: (1) low volume (<10 and <100 cases, respectively), (2) intermediate volume (10–150 and 100–400 cases, respectively), and (3) high volume (>150 and >400 cases, respectively). Patient demographics, comorbidities, hospital academic status, and LOS were identified. Univariate and multivariate analyses were performed to compare hospital-, surgeon-, and patient-related factors.
Results: Neither hospital (P = 0.173) volume nor surgeon (P = 0.413) volume were significantly associated with LOS in multivariate analyses while controlling for patient-, surgeon-, and hospital-related factors. Patient medical factors including diabetes (P < 0.001), congestive heart failure (P < 0.001), peripheral vascular disease (P < 0.001), chronic kidney disease (P < 0.001), chronic obstructive pulmonary disease (P < 0.001), and anemia (P < 0.033), as well as academic teaching hospitals (P < 0.001) were associated with a significant increase in hospital LOS.
Conclusion: Patient’s chronic medical conditions and hospital status as an academic teaching hospital were found to be the most important associated risk factors on post-operative hospital LOS after TKA. This study directs the focus onto pre-operative optimization and patient selection and helps demonstrate where to best allocate resources to successfully decrease LOS.
Keywords: Lengths of stay, Total knee arthroplasty, Pre-operative optimization, Complications, High volume surgeon.


1. Hoffmann JD, Kusnezov NA, Dunn JC, Zarkadis NJ, Goodman GP, Berger RA. The shift to same-day outpatient joint arthroplasty: A systematic review. J Arthroplasty 2018;33:1265-74.
2. Burn E, Edwards CJ, Murray DW, Silman A, Cooper C, Arden NK, et al. Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: Evidence from linked primary care and NHS hospital records from 1997 to 2014. BMJ Open 2018;8:e019146.
3. Kreder HJ, Grosso P, Williams JI, Jaglal S, Axcell T, Wal EK, et al. Provider volume and other predictors of outcome after total knee arthroplasty: A population study in Ontario. Can J Surg 2003;46:15-22.
4. Styron JF, Koroukian SM, Klika AK, Barsoum WK. Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty. J Arthroplasty 2011;26:1418- 26.e1.
5. Yasunaga H, Tsuchiya K, Matsuyama Y, Ohe K. Analysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: Nationwide web-based survey. J Orthop Sci 2009;14:10-6.
6. Piuzzi NS, Strnad GJ, Sakr Esa WA, Barsoum WK, Bloomfield MR, Brooks PJ, et al. The main predictors of length of stay after total knee arthroplasty: Patient-related or procedure-related risk factors. J Bone Joint Surg Am 2019;101:1093.
7. Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am 2010;92:2643-52.
8. Prohaska MG, Keeney BJ, Beg HA, Swarup I, Moschetti WE, Kantor SR, et al. Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty. Knee 2017;24:634-40.
9. Winemaker M, Petruccelli D, Kabali C, de Beer J. Not all total joint replacement patients are created equal: Preoperative factors and length of stay in hospital. Can J Surg 2015;58:160-6.
10. Martino J, Peterson B, Thompson S, Cook JL, Aggarwal A. Day of week and surgery location effects on stay length and cost for total joint arthroplasty: Academic versus orthopaedic-specific hospital. J Knee Surg 2018;31:815-21.
11. Pamilo KJ, Peltola M, Paloneva J, Makela K, Hakkinen U, Remes V. Hospital volume affects outcome after total knee arthroplasty. Acta Orthop 2015;86:41-7.
12. Lavernia CJ, Guzman JF. Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty 1995;10:133-40.
13. Hervey SL, Purves HR, Guller U, Toth AP, Vail TP, Pietrobon R. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-nationwide inpatient sample. J Bone Joint Surg Am 2003;85:1775-83.

How to Cite this article: Willinger M, Gold P, Garbarino L, Anis H, Sodhi N, Danoff JR. What is associated with the Greatest Effect on Lengths of Stay after Total Knee Arthroplasty: The Hospital, the Surgeon, or the patient. Journal of Clinical Orthopaedics 2023:8(2);07-11.

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