Orthopedics

Feature Article 

Primary Total Hip Arthroplasty With Same-Day Discharge: Who Failed and Why

Kelvin Y. Kim, BA; Afshin A. Anoushiravani, MD; Ameer Elbuluk, BA; Kevin Chen, MA; Roy Davidovitch, MD; Ran Schwarzkopf, MD, MSc

Abstract

As the emphasis on value-based care within total joint arthroplasty increases, this procedure is becoming more prevalent in the outpatient setting. The goals of this study were to report on the authors' early experiences with same-day discharge and to identify patient characteristics that are associated with failure to discharge after total hip arthroplasty within this program. All patients who were enrolled in the same-day discharge total hip arthroplasty program at the study institution between January 2015 and July 2016 were included. Demographics, baseline characteristics, and clinical and quality outcomes were compared between patients who successfully completed this program and those who did not. Of the 163 study subjects, 143 (87.7%) were discharged successfully on the same day as surgery. Women, patients younger than 40 years, and patients older than 60 years all had an increased risk of failing the program. Body mass index of 26 kg/m2 or less was associated with a 40% greater risk of failure. Patients with an American Society of Anesthesiologists score of 3 had a 3-fold risk of failure compared with patients with an American Society of Anesthesiologists score of 2 or less. The screening protocol for same-day discharge at the study institution had an 87.7% rate of successful same-day discharge. Further investigation is needed to identify patients who are at risk of failing the same-day discharge initiative. [Orthopedics. 2018; 41(1):35–42.]

Abstract

As the emphasis on value-based care within total joint arthroplasty increases, this procedure is becoming more prevalent in the outpatient setting. The goals of this study were to report on the authors' early experiences with same-day discharge and to identify patient characteristics that are associated with failure to discharge after total hip arthroplasty within this program. All patients who were enrolled in the same-day discharge total hip arthroplasty program at the study institution between January 2015 and July 2016 were included. Demographics, baseline characteristics, and clinical and quality outcomes were compared between patients who successfully completed this program and those who did not. Of the 163 study subjects, 143 (87.7%) were discharged successfully on the same day as surgery. Women, patients younger than 40 years, and patients older than 60 years all had an increased risk of failing the program. Body mass index of 26 kg/m2 or less was associated with a 40% greater risk of failure. Patients with an American Society of Anesthesiologists score of 3 had a 3-fold risk of failure compared with patients with an American Society of Anesthesiologists score of 2 or less. The screening protocol for same-day discharge at the study institution had an 87.7% rate of successful same-day discharge. Further investigation is needed to identify patients who are at risk of failing the same-day discharge initiative. [Orthopedics. 2018; 41(1):35–42.]

As the demand for total joint arthroplasty continues to rise,1 increased emphasis is being placed on value-based care initiatives.2,3 To achieve these goals, recent efforts have been made to introduce total joint arthroplasty within the outpatient setting. The feasibility of the use of same-day discharge for total joint arthroplasty by substantially reducing complication profiles and length of stay while maintaining and even improving the postoperative outcomes associated with elective total joint arthroplasty has been shown by several landmark studies.2,4–8 Initiatives for same-day discharge for total joint arthroplasty have been made possible largely because of advances in regional anesthesia, improved patient education, integrated care pathways, and the use of multimodal pain management.9–11 As a result, outpatient total joint arthroplasty is no longer a pilot program at a limited number of tertiary care centers but an initiative that may be used at orthopedic centers across the country.

Within a short period, investigators have assessed different individual risk factors associated with outcomes among candidates for same-day surgery. However, few studies have evaluated in detail the 10% to 15%12 of these patients who ultimately fail the program. The current study comprehensively evaluated patients who were enrolled in the same-day discharge program at the study institution but ultimately failed to be discharged on the same day as surgery. The authors suspect that certain patient demographics, including older age, female sex, and lower body mass index, are associated with a higher risk of failing the program.

Materials and Methods

Study Design

The current retrospective observational cohort study was conducted at a single tertiary care center. Before chart review and data analysis were conducted, institutional review board approval was obtained. Patient charts were reviewed retrospectively using the institutional electronic medical records system. All patients enrolled in the same-day discharge total hip arthroplasty (THA) program between January 2015 and July 2016 were included in this study. No patient who successfully completed the same-day discharge THA program was excluded from the study. Comparison groups included patients who were successfully discharged on the same day as surgery and those who were not.

Same-Day Discharge Perioperative Management

All patients underwent THA at the study institution performed by 1 of 6 orthopedic surgeons. All same-day discharge THA candidates underwent risk stratification and medical optimization before surgical intervention. To qualify for the same-day discharge THA program, patients had to meet the following criteria: no history of coronary artery disease or arrhythmias, no current use of long-term anticoagulation, no history of moderate or severe sleep apnea, hemoglobin level of 12 g/dL or greater, and body mass index of 40 kg/m2 or less. Physicians discussed the risks, benefits, and alternative procedures with their patients. In addition, before the day of surgery, each patient was scheduled for an individual 2-hour meeting with a clinical care coordinator, as well as a physical and occupational therapist. During this meeting, the patient was educated on the expected recovery course, pain management modalities, physical therapy exercises, and postoperative expectations. Patients who no longer desired to participate in the same-day discharge THA program or who did not meet the program requirements could withdraw at any time before the day of surgery.

All patients who participated in the same-day discharge program received a standardized spinal anesthesia protocol. The specific anesthetic regimen administered during surgery included fentanyl, propofol, midazolam, and dexamethasone. Perioperatively, a uniform multimodal pain regimen was established that reduced the need for narcotics. This regimen included 3 mL of 0.25% bupivacaine and periarticular liposomal bupivacaine injections before closure. Patient-controlled analgesia and oral or intravenous opioid administration were strongly discouraged except when all alternatives had been exhausted. Finally, several non-narcotic medications, including oral acetaminophen and celecoxib, were routinely used for pain control. In addition, all patients received perioperative antibiotics for 24 hours and thromboprophylactic agents that consisted of either 325 mg or 81 mg of aspirin orally twice daily for 4 weeks. Further, all patients received mechanical prophylaxis during surgery and for 2 weeks following surgery. Active smokers were prescribed enoxaparin (40 mg/d for 4 weeks) instead of aspirin and compression devices, according to the institutional protocol.

Once they were deemed medically and functionally safe for discharge, all patients were discharged home with home health care services. On postoperative day 1, the clinical care coordinator nurse called all patients to ensure that they were doing well. Additionally, physical therapists and visiting nurses followed up with all patients at their homes to assist with wound care and rehabilitation intermittently for 2 weeks. All details of postoperative management were surgeon-specific and identical to those for patients undergoing inpatient THA procedures.

Baseline and Demographic Characteristics

Baseline and demographic characteristics were collected and examined for variability. Variables reported included patient age, sex, ethnicity, body mass index, and American Society of Anesthesiologists (ASA) score, a validated predictive tool used to stratify patients based on their comorbidity profile.13 In addition, social history, medications, and comorbidities were reviewed and analyzed.

Peri- and Postoperative Variables

Intra- and postoperative complications, length of stay, discharge disposition, revisions, and 30- and 90-day readmissions were retrospectively collected and evaluated. Length of stay was defined as the interval between the time the patient was admitted to the floor and the time the patient was discharged.

Statistical Analysis

All data were organized and collected with Excel software (Microsoft Corporation, Redmond, Washington). Statistical analysis was performed with Minitab 17 version 13.2 software (Minitab Inc, State College, Pennsylvania). Standard descriptive summaries of baseline and demographic characteristics were used (eg, mean and standard deviation for continuous variables). An analysis was performed to compare baseline characteristics and outcomes after same-day discharge THA for patients who successfully completed and those who failed the program. Categorical baseline characteristics and outcomes were analyzed with a chi-square test with Fisher's P value reported between the 2 groups. A Student's t test was used to compare group means between the 2 groups. In all instances, P<.05 was deemed significant. The effect of patient covariates, including all demographic factors, on whether patients were discharged on the same day as surgery was assessed individually with a univariate logistic regression analysis with a cutoff of P<.2. The covariates that fell within this threshold were subsequently included in a multivariate logistic regression analysis comparing these patient covariates (independent variable) and whether patients were discharged on the same day as surgery (dependent variable). Results were reported as odds ratios with 95% confidence intervals. For the multivariate analysis, significance was defined as P<.05 and a 95% confidence interval excluding 1.

Results

Baseline Characteristics

A total of 163 patients who participated in a same-day discharge THA program were included in this study. This cohort of patients constituted slightly more than 10% of all patients who underwent THA at the study institution during the 18-month study period. Of the 163 subjects, 52.8% were men and 47.2% were women. At the time of surgery, mean age was 55.5 years and mean body mass index was 26.9 kg/m2. Most subjects were white (87.1%). The mean ASA score was 1.9. Additionally, of the 163 subjects, 143 (87.7%) were discharged successfully on the same day as surgery.

Evaluation of the prevalence of variables that correlated with same-day discharge showed that male sex (P=.060), patient age between 51 and 60 years (P=.139), and ASA score of 2 (P=.039) were correlated with program success (Table 1). Conversely, patients who were older (range, 61–80 years) (P=.139) and had an ASA score of 3 (P=.039) were more likely to fail.

Baseline Characteristics of Patients With and Without Discharge on the Same Day as Surgery

Table 1:

Baseline Characteristics of Patients With and Without Discharge on the Same Day as Surgery

Quality Outcomes

Among the total same-day discharge cohort, mean length of stay was 9.6 hours (SD, ±2.4 hours) (Table 2). Comparison of length of stay between the 2 cohorts showed that those who were discharged on the same day as surgery stayed a mean of 4.8 hours after surgery and those not discharged on the same day had a mean length of stay of 31.2 hours. One patient in each cohort had a complication; however, all patients who had same-day discharge THA were discharged home. One patient who failed same-day discharge had an intraoperative complication (0.6%) consisting of femoral fracture during broaching that required an extended length of stay. A patient with successful same-day discharge had a periprosthetic joint infection that required irrigation and debridement on postoperative day 20.

Quality Outcomes for Patients With and Without Discharge on the Same Day as Surgery

Table 2:

Quality Outcomes for Patients With and Without Discharge on the Same Day as Surgery

Subanalysis of Patients Who Failed Same-Day Discharge

Subanalysis of patients who were discharged on the same day as surgery and those who were not was performed to evaluate patients who failed same-day discharge. Table 3 and the Figure provide a summary of patient characteristics, including medical and surgical history and reasons for discharge failure. Additionally, a multivariate analysis was performed to control for patient characteristics and identify specific preoperative variables predictive of failure (Table 4). This analysis showed that women were twice as likely to fail compared with men. Moreover, candidates for same-day discharge who were younger than 40 years, 61 to 70 years, and 71 to 80 years had a higher risk of failing the program. Body mass index of 26 kg/m2 or less was associated with a 40% greater risk of failure, and an ASA score of 3 was associated with a 3-fold higher risk of failure compared with an ASA score of 2 or less.

Characteristics of Patients Not Discharged on the Same Day as SurgeryCharacteristics of Patients Not Discharged on the Same Day as Surgery

Table 3:

Characteristics of Patients Not Discharged on the Same Day as Surgery

Reasons for failure of same-day discharge program. Abbreviations: EBL, estimated blood loss; intra-op, intraoperative; OR, operating room; Post-op, postoperative; PT, physical therapy.

Figure:

Reasons for failure of same-day discharge program. Abbreviations: EBL, estimated blood loss; intra-op, intraoperative; OR, operating room; Post-op, postoperative; PT, physical therapy.

Risk Factors for Patients Not Discharged on the Same Day as Surgery

Table 4:

Risk Factors for Patients Not Discharged on the Same Day as Surgery

Discussion

The health care climate has rapidly shifted from a fee-for-service system to a patient-centered, performance-based model. Within this health care environment, it has become essential for health care providers to deliver high-quality care in an economically responsible manner that is commonly referred to as value-based care. Health care organizations have rapidly implemented patient-centric programs that emphasize active patient involvement, patient risk stratification, and medical optimization, with the intent of reducing postoperative complications, decreasing length of stay, improving patient satisfaction, and ultimately improving postoperative outcomes.2,4–8 To address these heightened expectations, orthopedic surgeons have experimented with same-day discharge and short-stay (length of stay <2 days) total joint arthroplasty and have shown its feasibility within the appropriate patient population.7,8,14 A major challenge when implementing same-day discharge or short-stay surgical programs is the accurate and reliable screening of surgical candidates.

Although growing evidence supports the practice of same-day discharge after total joint arthroplasty, patient selection criteria have yet to be standardized. Many studies have investigated specific risk factors and their effect on length of stay and hospital readmission. Lovald et al8 reported that higher Charlson Comorbidity Index scores among patients with a medical history of diabetes or cardiovascular disease were associated with a significantly increased risk of hospital readmission after short-stay THA. Another study by the same authors evaluated patients who had undergone short-stay total knee arthroplasty and reported that existing comorbidities, particularly congestive heart failure, drastically increased the rate of postoperative complications, including readmission, reoperation, and mortality.7 Courtney et al14 developed a 6-point scale that showed that patients who had no history of chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, or cirrhosis had only a 3.1% risk of complications 24 hours after primary hip or knee arthroplasty.

Despite recent improvements in same-day discharge programs, studies have reported a 10% to 20% program failure rate.12,15 The current study showed that most participants in this same-day discharge THA program did remarkably well and were discharged on the same day as surgery; however, 20 (12.3%) patients were unable to be successfully discharged on the same day as surgery. The most common reasons for delayed discharge were postoperative hypotension and nausea and vomiting. These are not uncommon events after the administration of spinal anesthesia, and they affect up to 3.5% of patients undergoing THA.16 As a result of these findings, the current authors' institution has implemented a rigorous perioperative intravenous hydration policy and has begun to administer scopolamine patches to patients with a history of postoperative nausea and vomiting.

To better understand the reasons for increased length of stay, the authors subanalyzed the 20 patients who were not discharged on the same day as surgery (Table 3). The findings showed that women, patients with lower body mass index (≤26 kg/m2), and those with ASA scores of 3 were more likely to fail the program Further, the most common complications among female patients (and overall) were postoperative hypotension, nausea, and poor pain management, all of which are preventable.

The association between female sex and a higher risk of failure is particularly concerning because women undergo more than two-thirds of total joint arthroplasty procedures and 62% of patients diagnosed with preoperative anemia are women.17 This increased prevalence of preoperative anemia increases the entire risk profile for patients undergoing noncardiac elective procedures.17,18 Although the current study did not find a difference in the prevalence of anemia between men and women, previous studies showed that preoperative anemia is a risk factor for postoperative anemia, allogenic transfusion, and increased length of stay, ultimately resulting in increased patient mortality.17,18 In addition, the current findings suggest that women, particularly those with lower body mass index, may have an even higher incidence of postoperative hypotension and nausea. This finding may be incidental or may be related to the inability of these physically smaller patients to reach osmotic homeostasis immediately after surgery. This inability to balance fluids and electrolytes may be augmented by the decades-old practice of giving patients nothing by mouth after midnight, which further dehydrates patients and increases the risk of sudden osmotic changes (ie, perioperative fluid bolus).

Recommendations

Regardless of the preoperative screening instrument used, approximately 10% to 20% of participants in same-day discharge THA programs are not successfully discharged home on the same day as surgery. The reasons are complex and numerous and include subclinical psychosocial issues, problems with hospital operational logistics, and issues with social work and physical therapy. Yet, even with unforeseen events, further enhancements may be made to the current screening protocol used at the authors' institution. The authors suggest that female sex, especially in association with moderate to low body mass index, be considered among the variables associated with prolonged length of stay. Another nonmodifiable risk factor, ASA score, should be considered. Although ASA scores were not designed to screen patients undergoing total joint arthroplasty, the score provides an easily applicable assessment of a patient's health. The current study and others19 have reported that an ASA score of 3 or greater has been associated with higher odds of failing to be discharged on the same day as surgery.

Limitations

The results should be considered within the limitations of this study. A retrospective study design was used. As with all retrospective studies, there is concern about errors in the data collection process, susceptibility to various biases, and limitations to the ability to control for all study variables. Additionally, as shown by the wide confidence intervals, the sample was small and not sufficiently powered to investigate outcomes other than those directly related to program success and failure. This study provides a detailed account of consecutive patients in a same-day discharge program who underwent THA within an 18-month period. This critical evaluation of program successes and failures led to improvements to the same-day discharge initiative, enhancing future outcomes.

Conclusion

Currently, despite rigorous screening methods, 10% to 20% of participants who enroll in same-day discharge programs are not discharged on the same day as surgery. The current study identified multiple variables associated with prolonged length of stay among patients within the same-day discharge program. Early studies of the feasibility of same-day discharge programs have shown their valuable implications; however, further investigation is required to provide more accurate and reliable risk stratification for patients to maximize the benefits of same-day discharge programs.

References

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Baseline Characteristics of Patients With and Without Discharge on the Same Day as Surgery

CharacteristicTotal Patient Cohort (N=163)Discharge on Postoperative Day 0 (n=143)Discharge on Postoperative Day >0 (n=20)P
Age, mean (SD), y55.5 (8.3)55.4 (8.0)56.5 (10.2).139
Age range, y
  29–40, No. (SD)9 (5.5)7 (4.9)2 (10.0)
  41–50, No. (SD)28 (17.2)25 (17.5)3 (15.0)
  51–60, No. (SD)76 (46.6)71 (49.7)5 (25.5)
  61–70, No. (SD)49 (30.1)39 (27.3)10 (50.0)
  71–80, No. (SD)2 (1.2)1 (0.7)1 (10.0)
Sex, M:F, No.86:7879:647:14.060
American Society of Anesthesiologists score, No. (SD).039
  131 (19.0)27 (18.9)4 (20.0)
  2125 (76.7)112 (78.3)13 (65.0)
  37 (4.3)4 (2.8)3 (15.0)
  4000
  Mean (SD)1.85 (0.5)1.80 (0.4)1.90 (0.7)
Race, No. (%).771
  White142 (87.1)124 (86.7)18 (90.0)
  Black5 (3.1)4 (2.8)1 (5.0)
  Hispanic6 (3.7)5 (3.5)1 (5.0)
  Asian2 (1.2)2 (1.4)0
  Other8 (4.9)8 (5.6)0
Body mass index, mean (SD), kg/m226.9 (4.6)27.0 (4.5)25.9 (5.0).757
Body mass index range, kg/m2
  15–20, No. (SD)11 (6.7)9 (6.3)2 (10.0)
  21–25, No. (SD)57 (35.0)50 (35.0)7 (35.0)
  26–30, No. (SD)60 (36.9)54 (37.8)6 (30.0)
  31–35, No. (SD)30 (18.4)25 (17.5)5 (25.0)
  36–40, No. (SD)5 (3.1)5 (3.5)0

Quality Outcomes for Patients With and Without Discharge on the Same Day as Surgery

Quality OutcomeTotal Patient Cohort (N=163)Discharge on Postoperative Day 0 (n=143)Discharge on Postoperative Day >0 (n=20)P
Length of stay, mean (SD), h9.6 (2.4)4.8 (2.4)31.2 (19.2)<.001
Discharge disposition, No. (%).247
  Home with health care services154 (94.5)134 (93.7)20 (100)
  Home with self-care9 (5.5)9 (6.3)0
  Skilled nursing facility000
  Rehabilitation facility000
Intraoperative complications, No. (%)1 (0.6)01 (5) Femoral perforation during broaching.008
Postoperative complications, No. (%)1 (0.6) Periprosthetic infection requiring irrigation and debridement1 (0.7)0.707
30-day readmissions, No. (%)1 (0.6)1 (0.7)0.707
90-day readmission, No. (%)000
Revisions, No. (%)000

Characteristics of Patients Not Discharged on the Same Day as Surgery

Patient No./Sex/Age, yRaceBody Mass Index, kg/m2ASA ScoreReason for Failure to DischargeDetailsComorbiditiesNarcotic Pain MedicationsSurgical History
1/M/63White25.92Comorbidity monitoringMonitoring related to obstructive sleep apnea diagnosed 4 wk before surgeryHip arthritis, sleep apneaNANA
2/M/64White25.53Comorbidity monitoringMonitoring related to history of cardiac stent placement; patient was not appropriate candidate for SDDAnxiety, BPH, CAD, GERD, hyperlipidemia, hypertension, MI, stent in coronary arteryOxycodone-acetaminophen 5 to 325 mg q6h 5 mg oxycodone 325 mg acetaminophenHepatic abscess removal, coronary angioplasty with stent placement
3/F/62White32.23Late caseLate case, second dose of IV cefazolin administered at 9:45 pmArthritis, hypertension, hypothyroidism, osteoporosis, PFO, postoperative retention of urine, TIANACesarean section, vaginal reconstructionsurgery, hysterectomy
4/F/48White18.61ORHigh EBL (approximately 900 mL)IUD in place, migraine, osteoarthritisNANA
5/F/48White18.42ORHigh EBL (approximately 500 mL)Anxiety, depression, scoliosisNANA
6/M/30White34.52ORIntraoperative complications (stem perforation)Obesity, shinglesOxycodone-acetaminophen 5 to 325 mg 5 mg oxycodone 325 mg acetaminophenNA
7/F/43White21.81Postoperative hypotensionHypotensionCongenital hip dysplasiaNANA
8/F/61White23.72Postoperative hypotensionHypotension, sedation, fatigue, nausea (history of narcotic sensitivity)COPDNANA
9/F/64White26.52Postoperative hypotensionHypotension that responded to hydration, dizziness, lightheadedness, fatigue, nausea, vomitingArthritis, diskogenic low back pain, insomnia, liver disease, history of right hip replacementOxycodone 5 mg q4h PRNNA
10/F/52White24.72Postoperative hypotensionHypotension, nausea, vomitingArthritis, endometriosis, varicose veinsNANA
11/F/59White34.82Postoperative hypotensionHypotension, dizziness, drowsiness limited PT progressArthritis, cervical cancer, GERD, history of stomach ulcers, hypothyroidism, obesityNAHysterectomy
12/M/59White29.52Postoperative hypotensionVasovagal episode, hypotension that responded to hydration, severe painGERDOxycodone 5 to 325 mg 5 mg oxycodone 325 mg acetaminophenNA
13/F/39Asian23.81Postoperative nauseaNausea/vomiting that limited PT progressMigraine with aura, thyroid noduleOxycodone 5 mg q4h PRNKnee arthroscopy
14/F/58White21.12Postoperative nauseaSedation, fatigue, nausea (history of narcotic sensitivity)Mononucleosis, palpitations, papilloma of oral cavity, salmonellosisNA-
15/F/64Black28.22Postoperative pain, weaknessHypotension, drowsiness, nausea that limited PT progress, severe painHypothyroidism, osteoarthritis of hipNARemoval of ectopic pregnancy
16/F/64White32.92Postoperative pain, weaknessWeakness that limited PT progressNAOxycodone-acetaminophen 5 to 325 mg; 2 tablets q4hCesarean section
17/F/61White26.33Postoperative multiple conditionsOversedation, hypoxia, tachycardia, multifocal aspiration with computed tomographyAnemia, anxiety, arthritis, cecal volvulus, colitis, microscopic lymphocytic colitis, GERD, hyperlipidemiaNABariatric surgery, Cesarean section, gastric band, colon surgery
19/F/71White20.63Postoperative hypotensionPostoperative acute blood loss anemiaAortic regurgitation, asthma, Graves' disease, heart mur-mur, hyperlipidemia, hypertension, sciatica, scoliosisNATranscatheter aortic valve replacement
20/M/63White28.22Postoperative hypotensionPostoperative acute blood loss anemiaArthritis, history of asbestosis, hyperlipidemia, hypertensionNAKnee arthroscopy with meniscal repair

Risk Factors for Patients Not Discharged on the Same Day as Surgery

Risk FactorOdds Ratio (95% Confidence Interval)P
Female sex2.29 (0.86–6.09).066
Age, y
  <402.16 (0.42–11.20).667
  61–702.18 (0.84–5.67).033
  71–807.10 (0.43–63.06).449
Body mass index ≤26 kg/m21.41 (0.54–3.68).949
American Society of Anesthesiologists score >23.07 (0.55–16.99).441
Authors

The authors are from the Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York.

Mr Kim, Dr Anoushiravani, Mr Elbuluk, and Mr Chen have no relevant financial relationships to disclose. Dr Davidovitch is a paid consultant for Exactech, Medtronic, and Radlink. Dr Schwarzkopf is a paid consultant for Smith & Nephew and Intellijoint, has received a grant from Smith & Nephew, and holds stock in Intellijoint.

Correspondence should be addressed to: Ran Schwarzkopf, MD, MSc, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 ( Ran.schwarzkopf@nyumc.org).

Received: July 29, 2017
Accepted: October 02, 2017
Posted Online: December 01, 2017

10.3928/01477447-20171127-01

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