Anesthesia technique, mortality, and length of stay after hip fracture surgery

Utility of spinal anesthesia in plastic surgery and other surgical subspecialties: A literature review

INTRODUCTION

Spinal anesthesia (SA) is commonly used within the specialties of orthopedic surgery, obstetrics and gynecology, spine surgery, and general surgery, and offers several benefits over general anesthesia (GA). However, SA is used much less frequently in plastic surgery. This review analyzed currently existing data on SA use across various surgical specialties and compared the benefits and complications of SA to those of GA, to assess its utility and potential for more widespread use in plastic surgery.

METHODS

A comprehensive literature review was conducted using the PubMed and Cochrane Library databases to evaluate the utility of SA in plastic surgery. Indications, contraindications, and data on the use of SA across various surgical specialties were reviewed. Benefits, complications, and cost-effectiveness were also assessed. Finally, the utility of SA in plastic surgery was evaluated based on the available literature.

RESULTS

SA has been shown to yield several benefits and fewer risks than GA, including a higher possibility of early discharge, decreased costs, better pain and postoperative nausea and vomiting control, and decreased risk of deep venous thrombosis and pulmonary embolism.

CONCLUSION

Although commonly used for procedures across various surgical specialties such as obstetrics and gynecology, urology, and orthopedic surgery, SA is less frequently used within plastic surgery. Plastic surgery procedures that would benefit from the use of SA include those below the umbilicus such as liposuction, lower extremity procedures, and perineal procedures, and owing to its benefits, we recommend that SA be used more often within plastic surgery under appropriate clinical circumstances.

The Impact of Race/Ethnicity on Disparities in Utilization and Outcomes of Neuraxial Anesthesia for Hip and Femoral Shaft Fractures

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex-race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p < 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p < 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population.

Comparing perioperative outcomes between regional anesthesia and general anesthesia in patients undergoing hip fracture surgery: a systematic review and meta-analysis

PURPOSE

Nearly all patients with hip fractures undergo surgical treatment. The use of different anesthesia techniques during surgery may influence the clinical outcomes. The optimal anesthetic technique for patients undergoing hip fracture surgery is still controversial. We performed this updated systematic review and meta-analysis to compare clinical outcomes of patients undergoing hip fracture surgery with different anesthesia techniques.

SOURCE

Articles published from 2000 to May 2023 were included from MEDLINE, Embase, Web of Science, and the Cochrane Library. We included randomized controlled trials and observational studies comparing general anesthesia (GA) with regional anesthesia (RA) for the outcomes of 30-day mortality, 90-day mortality, in-hospital mortality, perioperative complications, length of hospital stay, and length of surgery in patients undergoing hip fracture surgery. Subgroup analyses were performed for the outcomes based on study design (randomized controlled trials or observational studies). We used a random-effects model for all analyses.

PRINCIPAL FINDINGS

In this meta-analysis, we included 12 randomized controlled trials. There was no difference in postoperative 30-day mortality between the two groups (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44 to 1.74; I2 = 0%). The incidence of intraoperative hypotension was lower in patients who received RA vs GA (OR, 0.52; 95% CI, 0.38 to 0.72; I2 = 0%). No significant differences were observed in 90-day mortality, in-hospital mortality, postoperative delirium, pneumonia, myocardial infarction, venous thromboembolism, length of surgery, and length of hospital stay.

CONCLUSION

In this updated systematic review and meta-analysis, RA did not reduce postoperative 30-day mortality in hip fracture surgery patients compared to GA. Fewer patients receiving RA had intraoperative hypotension than those receiving GA did. Apart from intraoperative hypotension, the data showed no differences in complications between the two anesthetic techniques.

STUDY REGISTRATION

PROSPERO (CRD42023411854); registered 7 April 2023.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

BACKGROUND

We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

OBJECTIVE

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

DESIGN

A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

MAIN MEASURES

30-day (primary) and 90-day (secondary) all-cause mortality.

KEY RESULTS

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

LIMITATIONS

The study used claims-based data.

CONCLUSIONS

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Intraoperative Use of High-Flow Nasal Cannula in Elderly Patients Undergoing Hip Fracture Repair Under Spinal Anesthesia: A Randomized Controlled Study

BACKGROUND

The procedure of hip fracture repair poses a risk for postoperative pulmonary complications (PPCs) in elderly patients, accompanied by anesthesia and operations. Various noninvasive methods of respiratory support are used as prophylactic and therapeutic, mainly in the postoperative period.  Objective: This study aims to determine whether intraoperative use of a high-flow nasal cannula (HFNC) impacts elderly patient outcomes after hip fracture surgery.

METHOD

Seventy patients aged 65 and older undergoing traumatic hip surgery under spinal anesthesia for isolated hip fractures were randomly assigned to either an interventional group (I) utilizing a high-flow nasal cannula or a control group (C) without respiratory intervention in a six-month single-blind controlled study at Sahloul Teaching Hospital.

RESULTS

The two groups had identical socio-demographic traits and baseline data. Respiratory postoperative complications occurred in two patients in group (I) and in nine patients in group (C), with a significant difference (p = 0.023). The main respiratory postoperative complications in group (I) were atelectasis (one case) and pulmonary edema (one case). The main respiratory postoperative complications in group (C) were atelectasis (four cases), pneumonia (two cases), COPD decompensation (two cases), and pulmonary edema (one case). No intensive care unit admissions or intraoperative complications were associated with using HFNC. The mean length of stay (LOS) in the hospital was 8.83 ± 2.91 for group I and 10.46 ± 3.4 for group (C), which differed significantly (p = 0.03) with no in-hospital mortality for the two groups.

CONCLUSION

The intraoperative administration of HFNC may lower the incidence of postoperative respiratory complications and the duration of hospital stays.

Anesthetic Methods for Hip Fracture

PURPOSE OF REVIEW

To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes.

RECENT FINDINGS

This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.

Predictive Factors for Length of Stay in Patients Undergoing Total Hip Arthroplasty: A Cross-Sectional Study

Background

Total hip arthroplasty (THA) is an effective surgery for patients with end-stage hip joint degenerative arthritis. This study aimed to determine peri-operative factors that impact the length of stay (LOS) and design a formula to predict LOS in patients undergoing THA.

Methods

This cross-sectional study was performed from September 2019 to January 2020. For this study, all patients who underwent THA over a period of 12 years since 2005 were included in the study. Data about the LOS and several variables including demographic variables, surgery-related variables, transfusion, intensive care unit (ICU) admission, past drug history, comorbidities, and laboratory data, were gathered. Qualitative variables are presented as numbers (%), and quantitative variables are presented as mean Mann± standard deviation. Mann Whitney test , Kruskal-Wallis test, and Spearman's rank correlation test were also used.

Results

A total of 524 patients were included in the study; 12 were excluded .261 (51%) were female and 251(49%) male. The mean age was 56.13±17.04 years. In the univariate analysis, the day of admission, surgery indication, transfusion, diabetes mellitus, oral anti-diabetic drugs, American Society of Anesthesiology (ASA) score, preoperative hemoglobin (Hb) level, and type of prosthesis showed significant relation with LOS. Significant variables entered to zero truncated negative binomial regression. Among them, the day of admission, ASA score, preoperative Hb level, and type of prosthesis showed significant relation with LOS (P < 0.05) and were used for model design.

Conclusion

Preoperative Hb level, ASA score, day of admission, and prosthesis type have an impact on LOS and can predict LOS in patients who are candidates for THA.

Effects of neuraxial or general anaesthesia on postoperative adverse events in oldest-old patients (aged 90 years and older) with intertrochanteric fractures: a retrospective study

BACKGROUND

To retrospectively analyse postoperative adverse events in oldest-old patients (aged 90 years and older) with intertrochanteric fractures treated under various anaesthetic techniques.

METHODS

A total of 153 consecutive patients participated in this study, of which 127 patients who underwent surgery with neuraxial anaesthesia or general anaesthesia for intertrochanteric fractures between October 2019 and October 2022 were eligible and evaluated. They were divided into the neuraxial anaesthesia and general anaesthesia groups. The demographic characteristics and postoperative adverse events were compared between the two groups.

RESULTS

A total of 13 patients (10.24%), including 6 in the neuraxial anaesthesia group (8.22%) and 7 in the general anaesthesia group (12.96%), died within 30 days after surgery. No significant differences between the two groups were observed. Postoperative delirium occurred in 40 patients (31.49%), including 17 (23.29%) in the neuraxial anaesthesia group and 23 (42.59%) in the general anaesthesia group; there was a significant difference between the two groups [P = 0.02, odds ratio (OR) = 0.41]. The other postoperative adverse events, including heart failure, acute stroke, acute myocardial infarction, pulmonary disease, anaemia, deep vein thrombosis, hypoproteinaemia, and electrolyte disorders, were not significantly different between the two groups.

CONCLUSION

Our data suggest that different anaesthesia methods do not affect the incidence of adverse events, such as death within 30 days after surgery in oldest-old patients with intertrochanteric fractures. However, more patients developed delirium after surgery in the general anaesthesia group (23, 42.59%) than in the neuraxial anaesthesia group (17, 23.29%); this may indicate that spinal anaesthesia reduces the incidence of postoperative delirium (P = 0.02, OR = 0.41).

TRIAL REGISTRATION

Retrospectively registered.

Total intravenous anesthesia for geriatric hip fracture with severe systemic disease

PURPOSE

Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery.

METHODS

We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics.

RESULTS

There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates.

CONCLUSION

Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

How well can fine balance work for covariate balancing

Fine balance is a matching technique to improve covariate balance in observational studies. It constrains a match to have identical distributions for some covariates without restricting who is matched to whom. However, despite its wide application and excellent performance in practice, there is very little theory indicating when the method is likely to succeed or fail and to what extent it can remove covariate imbalance. In order to answer these questions, this paper studies the limits of what is possible for covariate balancing using fine balance and near-fine balance. The investigations suggest that given the distributions of the treated and control groups, in large samples, the maximum achievable balance by using fine balance only depends on the matching ratio (ie, the ratio of the sample size of the control group to that of the treated group). In addition, the results indicate how to estimate this matching ratio threshold without knowledge of the true distributions in finite samples. The findings are also illustrated by numerical studies in this paper.

Days alive and at home after hip fracture: a cross-sectional validation of a patient-centred outcome measure using routinely collected data

BACKGROUND

Days alive and at home (DAH) is a patient centered outcome measureable in routinely collected health data. The validity and minimally important difference (MID) in hip fracture have not been evaluated.

OBJECTIVE

We assessed construct and predictive validity and estimated a MID for the patient-centred outcome of DAH after hip fracture admission.

METHODS

This is a cross-sectional observational study using linked health administrative data in Ontario, Canada. DAH was calculated as the number of days alive within 90 days of admission minus the number of days hospitalised or institutionalised. All hospital admissions (2012-2018) for hip fracture in adults aged >50 years were included. Construct validity analyses used Bayesian quantile regression to estimate the associations of postulated patient, admission and process-related variables with DAH. The predictive validity assessed was the correlation of DAH in 90 days with the value from 91 to 365 days; and the association and discrimination of DAH in 90 days predicting subsequent mortality. MID was estimated by averaging distribution-based and clinical anchor-based estimates.

RESULTS

We identified 63 778 patients with hip fracture. The median number of DAH was 43 (range 0-87). In the 90 days after admission, 8050 (12.6%) people died; a further 6366 (10.0%) died from days 91 to 365. Associations between patient-level and admission-level factors with the median DAH (lower with greater age, frailty and comorbidity, lower if admitted to intensive care or having had a complication) supported construct validity. DAH in 90 days after admission was strongly correlated with DAH in 365 days after admission (r=0.922). An 11-day MID was estimated.

CONCLUSION

DAH has face, construct and predictive validity as a patient-centred outcome in patients with hip fracture, with an estimated MID of 11 days. Future research is required to include direct patient perspectives in confirming MID.

Patient engagement in perioperative settings: A mixed method systematic review

BACKGROUND

Patient engagement has emerged as a key focus in the research literature to facilitate patients' recovery. The term is commonly used by researchers, yet without working definitions. This lack of clarity is further complicated by the interchangeable use of a few terms.

OBJECTIVES

This systematic review aimed at identifying how patient engagement was conceptualised and operationalised in perioperative settings.

METHODS

MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched for publications in English discussing patient engagement during the perioperative phase. Three reviewers conducted study selection and methodological assessment using Joanna Briggs Institute mixed methods review framework. Reflexive thematic analysis was used to analyse qualitative data and descriptive analysis for quantitative data.

FINDINGS

Twenty-nine studies were included with a total sample of 6289. Study types included qualitative (n = 14) and quantitative (n = 15) with different types of surgery. Sample sizes ranged from n = 7 to n = 1315. Only 38% (n = 11) of included studies offered an explicit definition. Four themes associated with operationalisation included provision of information, which was most studied theme, communication, decision-making and action-taking behaviours. All four themes were interconnected and co-dependent on each other.

CONCLUSIONS

Patient engagement in perioperative settings is a complex and multifaceted concept. The conceptual void in the literature calls for more theoretically informed and comprehensive approaches to researching surgical patient engagement. Future research should aim to better understand the factors that influence patient engagement, as well as the impact of different forms of engagement on patient outcomes through the whole surgical journey of a patient.

General anesthesia is an acceptable choice for hip fracture surgery

The debate over the optimal type of anesthesia for hip fracture surgery continues to rage. While retrospective evidence in elective total joint arthroplasty has suggested a reduction in complications with neuraxial anesthesia, previous retrospective studies in the hip fracture population have been mixed. Recently, two multicenter randomized, controlled trials (REGAIN and RAGA) have been published that examined delirium, ambulation at 60 days, and mortality in patients with hip fractures who were randomized to spinal or general anesthesia. These trials enrolled a combined 2,550 patients and found that spinal anesthesia did not confer a mortality benefit nor a reduction in delirium or greater proportion who could ambulate at 60 days. While these trials were not perfect, they call into question the practice of telling patients that spinal anesthesia is a "safer" choice for their hip fracture surgery. We believe a risk/benefit discussion should take place with each patient and that ultimately the patient should choose his or her anesthesia type after being informed of the state of the evidence. General anesthesia is an acceptable choice for hip fracture surgery.

Association between additional weekend rehabilitation and in-hospital mortality in patients with hip fractures

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Methods

A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups.

Results

The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group.

Conclusion

Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted.

Regional versus general anesthesia in older patients for hip fracture surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The optimal anesthesia technique for older patients undergoing hip fracture surgery remains controversial. We performed a systematic review and meta-analysis of updated randomized controlled trials (RCTs) to assess whether regional anesthesia was superior to general anesthesia in hip fracture surgery.

METHODS

We searched PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from January 2000 until April 2022. RCTs directly comparing regional and general anesthesia in hip fracture surgery were included in the analysis. The incidence of delirium and mortality were the primary outcomes and other perioperative outcomes including complications were secondary outcomes.

RESULTS

Thirteen studies involving 3736 patients were included in this study. There was no significant difference in the incidence of delirium (odds ratio [OR] 1.09; 95% confidence interval [CI] 0.86, 1.37) and mortality (OR 1.08; 95% CI 0.71, 1.64) between the two groups. Patients receiving regional anesthesia in hip fracture surgery were associated with a reduction in operative time (weighted mean difference [WMD]: - 4.74; 95% CI - 8.85, - 0.63), intraoperative blood loss (WMD: - 0.25; 95% CI - 0.37, - 0.12), postoperative pain score (WMD: - 1.77; 95% CI - 2.79, - 0.74), length of stay (WMD: - 0.10; 95% CI - 0.18, - 0.02), and risk of acute kidney injury (AKI) (OR 0.56; 95% CI 0.36, 0.87). No significant difference was observed in the other perioperative outcomes.

CONCLUSIONS

For older patients undergoing hip fracture surgery, RA did not significantly reduce the incidence of postoperative delirium and mortality compared to GA. Due to the limitations of this study, the evidence on delirium and mortality was still inconclusive and further high-quality studies are needed.

Does total hip arthroplasty result in intercostal nerve injury? A case report and literature review

Neuropathy in surgical-related locations has received concerns after total hip arthroplasty (THA), while the contralateral intercostal nerve (ICN) injury has not been reported. A 25-year-old female patient with a body mass index (BMI) of 17.9 kg/m² visited the orthopedic outpatient clinic with complaints of progressive left hip pain for 20 days. She was diagnosed with left end-stage hip osteoarthritis and developmental dysplasia of the bilateral hips after radiographs and a detailed history-taking. After painstaking consideration, a cementless THA with the standard posterolateral approach was performed under general anesthesia. The procedure was difficult but successful. Unexpectedly, the numbness and slight tingling in the skin of the right breast, lateral chest wall, and axilla cropped up on the first postoperative day. Following the clinical features and the conclusion of the multidisciplinary discussion, we assume that ICN neuropathy is the diagnosis in this case due to compression of the lateral decubitus position during the operation. Her symptoms completely disappeared after using mecobalamin injection (0.5 mg, intramuscular injection, every other day) for 11 days. The Harris left hip score improved from 39 to 94, and the visual analogue scale from 7 was reduced to 2 on the day of discharge. There were no other complications within the first year after the operation. For THA, we should pay attention to some unexpected complications by virtue of the special position, especially in thin and low-BMI people, which suggested that further comprehensive perioperative nursing measures and the beneficial surgical position and anesthesia type were called for.

General versus Neuraxial Anesthesia on Clinical Outcomes in Patients Receiving Hip Fracture Surgery: An Analysis of the ACS NSQIP Database

Whether the use of neuraxial anesthesia or general anesthesia leads to more favorable postoperative outcomes in patients receiving hip fracture surgery remains unclear. We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Data Files between 2016 and 2020 to investigate the association of neuraxial anesthesia and general anesthesia with morbidity and mortality after hip fracture surgery. Inverse probability of treatment weighting (IPTW) was used to balance the baseline characteristics, and multivariable Cox regression models were used to estimate the hazard ratio (HR) with a 95% confidence interval (CI) for postoperative morbidity and mortality among the different anesthesia groups. A total of 45,874 patients were included in this study. Postoperative adverse events occurred in 1087 of 9864 patients (11.0%) who received neuraxial anesthesia and in 4635 of 36,010 patients (12.9%) who received general anesthesia. After adjustment for IPTW, the multivariable Cox regressions revealed that general anesthesia was associated with increased risks of postoperative morbidity (adjusted HR, 1.19; 95% CI, 1.14-1.24) and mortality (adjusted HR, 1.09; 95% CI, 1.03-1.16). The results of the present study suggest that, compared with general anesthesia, neuraxial anesthesia is associated with lower risks of postoperative adverse events in patients undergoing hip fracture surgery.

Perioperative outcomes in different anesthesia techniques for patients undergoing hip fracture surgery: a systematic review and meta-analysis

BACKGROUND

Previous studies of the perioperative effects of general and regional anesthesia in adult patients undergoing effects of different anesthesia techniques on patients undergoing hip fracture surgery have not produced consistent results. The aim of this systematic review and meta-analysis was to compare the hip fracture surgery.

METHODS

We performed a systematic review and meta-analysis to compare the effects of general anesthesia with regional anesthesia on in-hospital mortality, 30-day mortality, postoperative pneumonia, and delirium in adult hip fracture patients (≥ 18 years). Between January 1, 2022, and March 31, 2023, a systematic search was performed for retrospective observational and prospective randomized controlled studies in PubMed, Ovid Medline, Cochrane Library, and Scopus.

RESULTS

Twenty-one studies including 363,470 patients showed higher in-hospital mortality in the general anesthesia group compared with regional anesthesia (OR = 1.21; 95% CI 1.13-1.29; P < 0.001, n = 191,511). The 30-day mortality (OR = 1.00; 95% CI 0.96-1.05; P = 0.95, n = 163,811), the incidence of postoperative pneumonia (OR = 0.93; 95% CI 0.82-1.06; P = 0.28, n = 36,743) and the occurrence of postoperative delirium in the two groups (OR = 0.94; 95% CI 0.74-1.20; P = 0.61, n = 2861) had no significant difference.

CONCLUSION

Regional anesthesia is associated with reduced in-hospital mortality. However, the type of anesthesia did not affect the occurrence of 30-day mortality, postoperative pneumonia, and delirium. A large number of randomized studies are needed in the future to examine the relationship between type of anesthesia, postoperative complications, and mortality.

[Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]

BACKGROUND

Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice.

MATERIAL AND METHODS

In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used.

RESULTS

The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26).

DISCUSSION

RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement.

Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU)

BACKGROUND

Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU).

METHODS

A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models.

RESULTS

A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 - 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 - 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group.

CONCLUSIONS

SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS.

Bupivacaine hypobare dans l’anesthésie rachidienne continue pour fracture de la hanche du vieillard : Les effets hémodynamiques (Etude prospective randomisée)

INTRODUCTION

Continuous spinal anesthesia for surgical repair of hip fracture in elderly patients has been shown to preserve hemodynamics better than general and single shoot spinal anesthesia. However, hypotension still occurs, even with continuous spinal anesthesia.

AIM

This study aimed to demonstrate that hypobaric bupivacaine is more effective in preserving hemodynamics than isobaric bupivacaine when patients are operated in lateral position.

METHODS

It was a prospective randomized controlled single-blind study conducted in an orthopaedic institute during two years (2017-2018). One hundred and ten patients aged more than 65 years, scheduled for hip fracture repair, were randomized to receive either hypobaric or isobaric bupivacaine. Repeated doses of 2.5 mg bupivacaine were injected until sensory blockade reached T12. Hypotension and severe hypotension were defined as a decrease of more than 20% and 30% from the baseline systolic arterial blood pressure and were treated with ephedrine. Statistical analysis used Chi2 and Student tests to compare either number and percentage or mean and median. P<0.05 was significant.

RESULTS

Less patients experienced hypotension and severe hypotension in hypobaric group than in isobaric group (respectively 53% vs. 73%; p<0.05 and 22% vs. 53%; p< 0.01). Ephedrine consumption was significantly lower in hypobaric group (1.9 mg vs. 5.6 mg; p<0.01).

CONCLUSION

Hypobaric bupivacaine may be used rather than isobaric bupivacaine for further preserving hemodynamics in continuous spinal anesthesia for hip fracture surgery in elderly.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy

OBJECTIVES

To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block.

DESIGN

Retrospective.

SETTING

Orthopedic specialty hospital.

PATIENTS/PARTICIPANTS

40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used.

INTERVENTION

Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve.

MAIN OUTCOME MEASUREMENTS

Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates.

RESULTS

A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates.

CONCLUSIONS

The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

General Anesthesia Versus Regional Anesthesia in the Elderly Patients Undergoing Hip Fracture Surgeries: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Surgery is the preferred treatment option for the elderly patients with hip fractures. However, the choice of general anesthesia (GA) or regional anesthesia (RA) remains controversial. The quality of evidence has further improved with the advent of several high-quality randomized clinical trials (RCTs) in the last two years. The purpose of this study was to compare the clinical outcomes of two anesthetic techniques in elderly patients undergoing hip fracture surgeries.

METHODS

Eligible studies were identified from PubMed/MEDLINE, Web of Science, Scopus, EMBASE and reference lists from January 2000 to June 2022 in this current systematic review and meta-analysis. The outcomes included the surgery-related outcomes (duration of surgery, duration of anesthesia, intraoperative blood loss and number of transfusions) and postoperative outcomes (30-day mortality, postoperative delirium,cardiovascular events and other complications).

RESULTS

A total of 10 RCTs were included, and a total of 3594 patients were analyzed. RA was associated with shorter duration of surgery, shorter length of hospital stays and less intraoperative blood loss compared to GA. There were no significant differences between the two groups in the number of blood transfusions, duration of anesthesia, 30-day mortality or postoperative delirium.

CONCLUSIONS

Our pooled analysis identified no significant differences in terms of the safety between RA and GA, while RA reduces intraoperative blood loss, length of hospital stays and duration of surgery. These results suggest that RA appears to be preferable for the elderly patients with hip fractures.

Enhanced recovery program - Impact of ASA grade on length of hospital stay in patients undergoing hip and knee arthroplasties

INTRODUCTION

Total hip and knee arthroplasties are two of the most quality of life enhancing orthopedic procedures performed. Enhanced recovery (ER) programs have been implemented in orthopedic surgery and have helped optimize preoperative, perioperative, and postoperative factors to reduce the physiological and psychological stress of surgery. The American Society of Anesthesiologists [ASA] classification system is now the most widely collected system for measuring physical health status by hip and knee arthroplasty registries worldwide. The aim of the study is to determine whether the ASA score is a predictive of length of hospital stay in patients undergoing hip and knee surgeries in elective setting.

METHODS

Retrospective data is collected from a consecutive series of 441 charts and Irish National Orthopedics Register (INOR) for patients who underwent elective primary hip & knee replacements from January 1, 2018 to December 31, 2018 in Our Lady's Hospital, Navan. All these patients were assigned either ASA Class 2 or 3 in preoperative assessment.

RESULTS

Total 441 patients were included. Patients with ASA 2 (319 patients of the total patient for the same period), average length of hospital stay was 4.8 ± 1.2 days, whereas for patients with ASA 3 (122 patients of the total), length of hospital stay was 6.5 ± 2.3 with mean difference between two groups was 1.7 days (95% confidence interval of this difference).

CONCLUSION

Patients with ASA 2 stayed shorter in the hospital compared to patients with ASA 3. Therefore, we recommend that pre-operative patients' optimization to downgrade a patient from an ASA 3 to ASA 2, but prospective analysis would be beneficial to examine the resource implications of such an initiative as well as patient outcomes with longer term follow up.

A retrospective observational study on the types of anaesthesia in hip fracture surgery

BACKGROUND

There is no specific recommendation regarding the type of anaesthesia in hip fracture surgery.

OBJECTIVES

This study sought to examine the current local anaesthetic practice (general anaesthesia versus regional anaesthesia (RA)) in hip fracture surgery and to analyse their associations with perioperative outcomes.

METHODOLOGY

A retrospective observational study of hip fracture patients from April to December 2017 was undertaken. Patient characteristics and perioperative outcomes were analysed against the types of anaesthesia using multiple logistic regression.

RESULTS

One hundred and twelve out of 154 patients (72.7%) had a general anaesthesia. Patients from residential care facilities were more likely to receive general anaesthesia (OR = 2.9, 95% CI: 1.1, 7.4; P = 0.03). There was no significant association between type of anaesthesia and specific postoperative outcomes; however, patients with postoperative delirium and hypotension were more likely to have received general anaesthesia [OR = 1.7, 95% CI: 0.68, 4.38; P = 0.25] and [OR = 1.6, 95% CI: 0.67, 4.04; P = 0.27] respectively). Subgroup analysis showed increased length of stay with patients who underwent general anaesthesia (OR = 1.26, 95% CI:1.04, 1.54; P = 0.02).

CONCLUSION

Regional anaesthesia may be considered in patients without contraindications in view of increased risk of postoperative delirium and hypotension, and longer length of stay with general anaesthesia. A larger prospective study is needed to confirm these findings.

Effect of General vs. Regional Anesthesia on Mortality, Complications, and Prognosis in Older Adults Undergoing Hip Fracture Surgery: A Propensity-Score-Matched Cohort Analysis

The choice of the type of anesthesia (TOA) used in hip fracture surgery in older adults is still controversial. The main question is not whether regional anesthesia (RA) or general anesthesia (GA) is superior, but in which patients the type of anesthesia may affect the outcome after surgery. In this retrospective analysis of surgically treated intertrochanteric fracture patients, we used propensity score matching (PSM) to investigate whether clinically relevant differences in outcomes were observed in mortality, complications, and functional outcomes between RA and GA. After screening 2934 consecutive patients, 2170 were ultimately included, including 841 in the GA group and 1329 in the RA group. After PSM, 808 remained in each group. Patients receiving GA were more prone to have a shorter duration for their operation and higher total hospital costs than patients with RA (p = 0.034 and 0.004, respectively). We also observed that the GA group has a higher rate of pulmonary complications, while the RA group has a higher rate of cardiac complications (p = 0.017 and 0.011, respectively). No significant difference was observed in mortality, functional outcomes, and other complications (all p > 0.05). The clinical innovation of this study was the potential value of GA for patients with cardiac diseases and of RA for patients with pulmonary diseases.

Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial

BACKGROUND

Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery.

METHODS

We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes.

RESULTS

A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65).

CONCLUSIONS

HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.

The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

BACKGROUND

Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.

METHODS

We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.

RESULTS

Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92-0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02-1.10) and return to original residence (OR=1.04, CI=1.00-1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.

CONCLUSIONS

Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery.

METHODS

A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology.

RESULTS

Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events.

CONCLUSIONS

No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.

Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice?

The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.

A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes

Objective

To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R).

Data sources

We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases.

Study selection

Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction.

Data extraction

The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared.

Data synthesis

Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group.

Conclusions

Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA.

Level of evidence

Therapeutic level III.

Dose Selection of Ropivacaine for Spinal Anesthesia in Elderly Patients with Hip Fracture: An Up-Down Sequential Allocation Study

Objective

The dose selection of ropivacaine for spinal anesthesia in clinical work mainly depends on the experience of the anesthesiologist. In this study, a prospective and modified up-down sequential allocation design was used to provide the optimal dose selection of ropivacaine for spinal anesthesia.

Patients and methods

This study was divided into two stages, and a total of 164 elderly patients with elective hip fractures were included. In stage I, the dose of ropivacaine was selected using the up-down sequential method of height correction, and the 50% effective dose (ED50) and 95% effective dose (ED95) were obtained. A nomogram for predicting satisfactory anesthesia and a formula for predicting the optimal dose was also given in this stage. In stage II, the dose of ropivacaine was calculated by using the optimal dose prediction formula, so as to evaluate the efficacy and safety of the model.

Results

The ED50 and ED95 of the stage I were 7.036 mg (95%CI 6.549–7.585 mg) and 8.709 mg (95%CI 7.902–14.275 mg), respectively. And provided a nomogram predicting satisfactory anesthesia with a C-index of 0.847 (95%CI 0.774–0.92). The optimal dose prediction formula of ropivacaine was calculated, including variables for age, gender, height, and weight. This formula was found to be 90% efficient. It is worth mentioning that the incidence of direct transfer to the ward in the two stages was as high as 86.84% and 93.33%, respectively, and no patients were transferred to the ICU in stage II.

Conclusion

The ED50 and ED95 of ropivacaine were 7.036 mg and 8.709 mg, respectively, and the nomograms are sufficiently accurate to predict satisfactory anesthesia. Beyond that, the dose prediction equation provided in this study has high efficacy and safety, and can guide the dose selection of spinal anesthesia in elderly patients with hip fracture in clinical practice.

Clinical trials registration

ChiCTR2100046982

Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis

Background

In older adults, the recovery after hip fracture surgery is not always to be well expected due to high risks of adverse outcomes including perioperative complications and mortality. We aimed to evaluate the intertrochanteric fracture (IF) patients with diabetes mellitus (DM) and receiving surgical fixation with intramedullary nail on the perioperative complications, total hospital costs (THC), length of hospital stay (LOS), and mortality.

Methods

In this retrospective cohort study, among 487 consecutive intertrochanteric fracture patients with age over 65 years and treated surgically by using intramedullary nail between Jan. 2015 and Mar. 2020, 353 patients were included, including 81 with DM and 272 without DM. After using propensity-score matched (PSM) analysis, 80 patients remained in each group. The perioperative complications, 30-day, 90-day, 1-year, and 2-year survival rates, THC, and LOS were observed and compared between two groups. Overall survival was compared by Kaplan–Meier method.

Results

No significant between-group differences were found in 30-day, 90-day, 1-year, and 2-year mortality rates, THC, LOS, and other perioperative complications after PSM and McNemar’s tests (all p>0.05), except for neurological complications (p<0.004) and endocrine/metabolic complications (p<0.001). At a mean follow-up time of 36.2 months, there were no statistically significant differences between the groups based on the Kaplan–Meier survival curve (p=0.171, log-rank).

Conclusion

IF surgery patients with DM are more prone to suffer perioperative neurological and endocrine/metabolic complications and they should be managed individually while being aware of these risks henceforth. Further high evidence clinical trials are needed to expand in DM patients with IF.

Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis

BACKGROUND

Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively.

METHODS

The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. "High-intensity" surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors.

RESULTS

In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (-1.0 morphine milligram equivalents per day difference; 95% CI, -1.4 to -0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small.

CONCLUSIONS

Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

EDITOR’S PERSPECTIVE

Effects of Spinal Anesthesia in Geriatric Hip Fracture: A Propensity-Matched Study

OBJECTIVES

To identify whether anesthesia type is associated with surgical outcomes in geriatric patients undergoing operative treatment for a hip fracture.

DESIGN

Retrospective database review of prospectively collected data.

PATIENTS

Patients included in the American College of Surgeons National Surgical Quality Improvement Program database. All included patients were 65-89 years of age and had a hip fracture treated with internal fixation, arthroplasty, or intramedullary device. Patients were excluded for open, pathologic, stress-related, or periprosthetic hip fractures.

INTERVENTION

Use of spinal anesthesia (SA) or general anesthesia (GA).

MAIN OUTCOME MEASUREMENTS

Complications, mortality, and discharge destination.

RESULTS

A total of 23,649 cases met inclusion and exclusion criteria and were successfully matched using propensity score matching: 15,766 GA and 7883 SA. The odds of sustaining a complication were 21% lower in the SA group compared with those in the GA group (odds ratio SA/GA 0.791; 95% confidence interval, 0.747-0.838). The 30-day mortality rate was not correlated with SA or GA choice. Patients who underwent SA were significantly more likely to be discharged to home (odds ratio SA/GA 1.65; 95% confidence interval, 1.531-1.773).

CONCLUSIONS

No mortality difference exists between patients undergoing SA and those undergoing GA for hip fracture surgery. For patients undergoing hip fracture surgery with SA, there is lower 30-day complication profile and higher discharge to home rate compared with those undergoing GA. Both anesthesia modalities may be acceptable.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health Services Research in Anesthesia: A Brief Overview of Common Methodologies

The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.

A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial

Background

Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.

Methods

A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.

Results

Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.

Conclusion

Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

Comparison of USG-guided or landmark approach fascia iliaca compartment block for positioning in elderly hip fracture patients with spinal anesthesia: a randomized controlled observational study

Background/aim

Currently, the elderly population in the world is rapidly increasing due to technological developments and convenient access to health services. Due to comorbidities in elderly patients, hip fractures are frequently observed after exposure to environmental trauma. To reduce pain during positioning in spinal anesthesia, fascia iliaca compartment block (FICB) can be applied easily and reliably. In our study, we aimed to compare the analgesic effects and duration of fascia iliaca compartment blocks performed with USG guidance or the landmark approach methods for relieving spinal anesthesia position pain.

Materials and methods

Our study included 100 patients undergoing operations due to hip fracture and administered spinal anesthesia after FICB. The group with USG-guided FICB (USG) had the blockage needle advanced to the compartment under the fascia iliaca, and 15 mL bupivacaine + 10 mL 2% lidocaine was administered. They were placed in sitting position for spinal anesthesia 20 min later and procedure duration and numerical rating scale (NRS) scores were recorded. In the group with landmark approach FICB (LAND), the spina iliaca anterior superior (SIAS) and pubic tubercle were connected with a line. The same amount of local anesthetic was administered to the external 1/3 portion of this line with the double pop technique. Procedure duration and NRS scores were recorded.

Results

There was no statistically significant difference between the two groups in terms of NRS scores (p: 0.073). There was a statistically significant difference in duration of FICB administration between the two groups (p < 0.001).

Conclusion

Both USG-guided and landmark approach FICB methods provide adequate and similar analgesia for positioning in spinal anesthesia. However, in cases where there is no problem with access to the ultrasound device or time, safer blockage can be provided by imaging neurovascular structures with ultrasound.

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

BACKGROUND

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study

BACKGROUND

Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients.

METHODS

After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated.

RESULTS

Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35).

CONCLUSIONS

Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Predictors of Difficult Ultrasound-Guided Transversus Abdominis Plane Blocks

Background

Fascial plane blocks are a valuable and important aspect of patient care. However, nerve blocks sometimes present with a technical difficulty that can lead to upsetting the operating room schedule, cause discomfort to the patient, or lead to inadequate block. Potential predictors of this difficulty were evaluated.

Methods

In a single-blind study, ultrasound image quality was evaluated on a grading metric, and its correlation with several factors that could potentially impact the difficulty of a procedure, including age, BMI, weight, length of surgery, IV fluids, and pre- vs postoperative block, was assessed.

Results

No correlation was found between any of our anesthetic, patient, or surgical factors, and the resulting image quality.

Conclusion

The study population was limited compared to our initial goals. We found no correlation between studied variables and image quality, but confounding factors that may affect image quality have not been ruled out.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures

OBJECTIVES

To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails.

DESIGN

Retrospective cohort study.

SETTING

The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital.

PATIENTS/PARTICIPANTS

Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study.

INTERVENTION

All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA).

MAIN OUTCOME MEASUREMENTS

Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost.

RESULTS

A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts.

CONCLUSIONS

This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Incidence of and risk factors for new-onset deep venous thrombosis after intertrochanteric fracture surgery

This study aimed to investigate the incidence of and risk factors for postoperative new-onset deep venous thrombosis (PNO-DVT) following intertrochanteric fracture surgery. Information on 1672 patients who underwent intertrochanteric fracture surgery at our hospital between January 2016 and December 2019 was extracted from a prospective hip fracture database. Demographic information, surgical data, and preoperative laboratory indices were analysed. Receiver operating characteristic curve analysis, univariate analyses and binary logistic regression analyses were performed. The incidences of postoperative deep venous thrombosis (DVT) and PNO-DVT in inpatients after intertrochanteric fracture surgery were 11.5% (202 of 1751 patients) and 7.4% (123 of 1672 patients), respectively. PNO-DVT accounted for 60.9% of postoperative DVT. Additionally, there were 20 cases of central thrombosis (16.3%), 82 cases of peripheral thrombosis (66.7%), and 21 cases of mixed thrombosis (17.1%). In addition, 82.1% of PNO-DVTs were diagnosed within 8 days after surgery. The multivariate analysis revealed that age > 70 years, duration of surgery (> 197 min), type of anaesthesia (general), and comorbidities (≥ 3) were independent risk factors for the development of PNO-DVT after intertrochanteric fracture surgery. This study demonstrated a high incidence of PNO-DVT in inpatients after intertrochanteric fracture surgery. Therefore, postoperative examination for DVT should be routinely conducted for patients.

Routinely collected data and patient-centred research in anaesthesia and peri-operative care: a narrative review

Randomised controlled trials are the gold standard in clinical research, but remain rare due to their expense and a perceived lack of 'real-world' applicability. At the same time, there has been an exponential increase in routinely collected data which presents opportunities for audit, quality improvement, adverse event reporting and more efficient clinical research. Registry-based research benefits from reduced cost, large sample size and real-world applicability, with methodological developments, particularly registry-based randomised controlled trials and causal inference techniques, showing promise. Limitations include data quality and validity, the need for data linkage, the restrictions of fixed data fields, regulatory barriers, and privacy and security concerns. However, the principal factor hampering current efforts is a lack of anaesthesia-specific datasets in the UK and the fact that most surgical registries do not collect any anaesthetic data. This presents an opportunity for anaesthetists, through enhanced engagement and collaboration, to influence and improve the design of these datasets and increase the value and volume of data collected. Better datasets, coupled with a growing appreciation of new analysis methodologies, would allow significant progress towards realising the potential of routinely collected data for patient benefit. At the same time, work should begin on the development of a minimum dataset for anaesthesia to underpin new data sharing networks and, ideally, a national registry of anaesthesia.

Association between surgical wait time and hospital length of stay in primary total knee and hip arthroplasty

AIMS

In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip.

METHODS

The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression.

RESULTS

A total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS.

CONCLUSION

Surgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS. Cite this article: Bone Jt Open 2021;2(8):679-684.