Risk factors for urinary retention after hip or knee replacement: a cohort study

Risk factors for postoperative urinary retention in patients underwent surgery for benign anorectal diseases: a nested case-control study

BACKGROUND

Postoperative urinary retention (POUR) is a common complication of anorectal surgery. This study was to determine the incidence of POUR in anorectal surgery for benign anorectal diseases, identify its risk factors, and establish a nomogram for prediction of POUR.

METHODS

A nested case-control study was conducted. The clinical data of patients were collected, and the incidence of POUR was analyzed. Univariate analysis was used to identify the risk factors associated with POUR, and multivariate logistic regression analysis was used to determine independent risk factors for POUR. A nomogram for the preoperative prediction of POUR using a logistic regression model was developed (n = 609).

RESULTS

The incidence of POUR after anorectal surgery for benign anorectal diseases was 19.05%. The independent risk factors for POUR were: female (P = 0.007); male with benign prostatic hyperplasia (BPH) (P = 0.001); postoperative visual analogue scale (VAS) score > 6 (P = 0.002); patient-controlled epidural analgesia (PCEA) (P = 0.016); and a surgery time > 30 min (P = 0.039). In the nomogram, BPH is the most important factor affecting the occurrence of POUR, followed by a postoperative VAS score > 6, PCEA, surgery time > 30 min, and sex has the least influence.

CONCLUSION

For patients undergoing anorectal surgery for benign anorectal diseases, preventive measures can be taken to reduce the risk of POUR, taking into account the following risk factors: female or male with BPH, severe postoperative pain, PCEA, and surgery time > 30 min. Furthermore, we developed and validated an easy-to-use nomogram for preoperative prediction of POUR in anorectal surgery for benign anorectal diseases.

TRIAL REGISTRATION

China Clinical Trial Registry: ChiCTR2000039684, 05/11/2020.

Risk factors of postoperative urinary retention following total hip and knee arthroplasty

Aims

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

Methods

Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively.

Results

A total of 31 studies were included in the systematic review. Of these, 29 studies entered our meta-analysis, which included 3,273 patients diagnosed with POUR and 11,583 patients without POUR following TJR. The pooled incidence of POUR was 28.06%. Demographic risk factors included male sex (OR 1.81, 95% CI 1.26 to 2.59), increasing age (SMD 0.16, 95% CI 0.04 to 0.27), and American Society of Anesthesiologists grade 3 to 4 (OR 1.39, 95% CI 1.10 to 1.77). Patients with a history of benign prostatic hyperplasia (OR 1.99, 95% CI 1.41 to 2.83) and retention (OR 3.10, 95% CI 1.58 to 6.06) were more likely to develop POUR. Surgery-related risk factors included spinal anaesthesia (OR 1.44, 95% CI 1.19 to 1.74) and postoperative epidural analgesia (OR 2.82, 95% CI 1.65 to 4.82). Total hip arthroplasty was associated with higher odds of POUR compared to total knee arthroplasty (OR 1.10, 95% CI 1.02 to 1.20). Postoperatively, POUR was associated with a longer length of stay (SMD 0.21, 95% CI 0.02 to 0.39).

Conclusion

Our meta-analysis demonstrated key risk variables for POUR following TJR, which may assist in identifying at-risk patients and direct patient-centered pathways to minimize this postoperative complication.

Patient-Controlled Analgesia and Peripheral Nerve Block Increase the Risk of Post-operative Urinary Retention after Total Knee Arthroplasty in Asian Patients

Introduction

Post-operative urinary retention (POUR) is a common complication after total knee arthroplasty (TKA) and may result in severe complications such as urinary tract infection and deep joint sepsis, leading to prolonged hospital stay and increased medical costs. Hence a retrospective study was performed to identify the incidence and modifiable factors associated with POUR after elective TKA in Asian patients with the aim to prevent POUR and its undesirable consequences.

Materials and Methods

The medical records of 496 consecutive patients who underwent elective TKA between 1 August 2017 and 30 July 2018 were reviewed. There were 154 male (31.0%) and 342 female (69.0%) patients with an average age of 68 years old. The incidence of POUR was analysed with respect to various modifiable and non-modifiable risk factors, including patient demographics, medical comorbidities, duration of surgery, type of intra-operative anaesthesia and post-operative analgesia and early initiation of physiotherapy using univariate and multivariate analyses.

Results

A total of 120 (24.2%) of the 496 patients who underwent elective TKA developed POUR. The odds of a patient with patient-controlled analgesia (PCA) and peripheral nerve block (PNB) developing POUR were 4.2 times and 4.7 times that of a patient without PCA and PNB, respectively. Age, male gender and type of anaesthesia were not found to be significant.

Conclusion

In our study population, the incidence of POUR after elective TKA was 24% with major modifiable risk factors being associated with the use of PCA and PNB as post-operative anaesthesia. POUR can have deleterious effects thus alternative post-operative analgesia should be considered.

Increased Duration of Total Hip and Total Knee Arthroplasty Surgery Increases the Risk of Post-Operative Urinary Retention: A Retrospective Cohort Study

Background: Post-operative urinary retention (POUR) is a common complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Spinal anaesthetic has been associated with an increased risk of POUR, whilst other risk factors remain unclear. This study aims to identify modifiable and non-modifiable risk factors of POUR for THA and TKA patients. Methods: A single-centre retrospective cohort study of patients admitted to our hospital over the course of 6 weeks from September to October 2021 for a THA or TKA. All patients who underwent elective THA/TKA were included, and trauma cases were excluded. Results: Ninety-two consecutive patients were included in this study. The overall rate of POUR was 17%. A shorter operative duration resulted in a reduced risk of POUR (median duration of non-retention patients, 88 min vs. 100 min POUR patients; odds ratio, 0.97; 95% CI, 0.95-0.99, p = 0.018). The median bladder volume of patients with urinary retention at the point of diagnosis was 614 mL (range, 298-999 mL). The arthroplasty type, anaesthetic technique, pre-operative morphine use, body mass index, age, cardiovascular disease, and renal disease were found to have no significant association with POUR. Conclusions: A reduced operative time of arthroplasty surgery is associated with a decreased risk of POUR. Patients with a prolonged operative time should have an increased frequency of micturition monitoring in the immediate post-operative period.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

Patients' experiences of urinary retention and bladder care - A qualitative study in orthopaedic care

BACKGROUND

Urinary retention is a common complication associated with hip surgery. There are easily available, evidence-based clinical practice guidelines prescribing how to prevent both urinary retention and other voiding issues, by means of bladder monitoring and risk assessments. A detected lack of adherence to such guidelines increases risks for unnecessary suffering among patients but a greater understanding of patients' experiences can benefit tailored interventions to address quality and safety gaps in orthopaedic nursing and rehabilitation.

PURPOSE

The aim was to describe patients' experiences of urinary retention, bladder issues, and bladder care in orthopaedic care due to hip surgery.

METHOD

This was a qualitative study with a descriptive design: content analysis with an inductive approach was applied to interviews (n = 32) and survey free-text responses (n = 122) across 17 orthopaedic units in Sweden.

RESULTS

The patients had received no or limited details for the recurrent bladder care interventions (such as bladder scans and prompted voiding) while at the hospital. They relied on the staff for safe procedures but were left to themselves to manage and comprehend prevailing bladder issues. Despite the patients' experiences of bladder issues or the risk of urinary retention postoperatively, the link to hip surgery remained unknown to the patients, leaving them searching for self-management strategies and further care.

CONCLUSIONS

Patients' perspectives on bladder care, urinary retention and bladder issues can serve as a means for increased understanding of procedures and issues, reinforcing improved implementation of guidelines, including person-centred information. Safer bladder procedures imply further patient engagement, highlighted in guidelines.

Mitigation of postoperative urinary retention among total joint replacement patients using the ERAS protocol and applying risk-stratified catheterization

BACKGROUNDS

We intended to identify the incidence and risk factors (RFs) for Postoperative urinary retention (POUR) after applying a risk-stratified catheterization optimization method in enhanced recovery after surgery (ERAS)-total joint arthroplasty (TJA).

METHODS

A total of 381 patients were prospectively monitored for POUR. POUR diagnosis was done by a perioperative specialist. Data on potential risk factors (RFs) for POUR were accumulated. Univariate analysis (UA) was conducted to identify possible indicators of POUR, followed by multivariate analysis (MA) of identified indicators.

RESULTS

POUR occurred in 5.5% of cases, including 8 (3.4%) patients underwent total knee arthroplasty and 13 (10.4%) patients underwent total hip arthroplasty. In UA, age, sex, American Society of Anesthesiologists (ASA) score, and the type of operation were significantly different on UA (P = 0.046, P = 0.022, P = 0.000 and P = 0.049, respectively). Other additional predictors, including body mass index (BMI), international prostate symptom score (IPSS) score, preoperative haemoglobin (Hb), duration of operation, estimated intraoperative blood loss, intraoperative fluid volume, fluid infusion volume within 24 h postoperatively were not associated with POUR (P > 0.05). MA results demonstrated that age, ASA score, type of operation and standard intraoperative placement of an indwelling bladder catheter (SIP-IBC) were strongly associated with POUR development risk (P < 0.05).

CONCLUSION

Overall, we had a low POUR incidence in our study cohort. However, with the shift from non-ERAS TJA to ERAS TJA protocol, it is crucial to closely monitor the male gender, advanced age, THA and SIP-IBC, as these variables can markedly enhance POUR risk.

The Role of Intraoperative Urinary Catheters on Postoperative Urinary Retention after Total Joint Arthroplasty: A Multi-Hospital Retrospective Study on 9,580 Patients

Background

Urinary catheters (UC) are used by some surgeons during total joint arthroplasty (TJA). This study investigated the impact of intraoperative urinary catheters on postoperative urinary retention (POUR) following TJA cases.

Methods

We conducted a retrospective comparative study across 11 medical centers on 9,580 TJA patients. Visits to urgent care or the emergency department within 7 and 30 postoperative days were reviewed. Medical records over a 12-month period for all patients older than 18 years old were used to gather demographic and surgical data as well as the incidence of urinary tract infection (UTI). Chi-squared tests (RStudio) were used to determine statistical significance against P-Values (P) < 0.05.

Results

13 (0.14%) patients returned within 7 days for POUR. POUR was more common in males [10 (0.3%) vs. 3 (0.1%) females, (P = 0.01)]. There was no difference in POUR when comparing total hip and knee arthroplasty procedures [0.16% vs. 0.12%, (P = 0.60)]. Of all operations, 25% had intraoperative UC use. There was no difference in POUR between the UC and no UC groups [0.21 vs. 0.11%, (P = 0.26)]. However, there was an increase in UTI in UC vs. no UC use within 7 postoperative days [0.92 vs. 0.43%, (P = 0.005)] and 30 postoperative days [2.60 vs. 1.50 %, (P < 0.001)].

Conclusion

In our study, there was no difference in POUR rates between the intraoperative UC vs. no UC groups. Therefore, the use of intraoperative UC may not decrease the rate of POUR following TJA procedures. Additionally, UTI risk was higher in the UC group which may be attributable to other factors, especially when comparing female vs. male patients.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors.

METHODS

Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis.

RESULTS

Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors.

CONCLUSION

A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION-a study protocol for a randomised trial by a multi-professional facilitator team and their first-line managers' implementation strategy

BACKGROUND

The Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION, project aims to progress knowledge translation vis-à-vis evidence-based bladder monitoring in orthopaedic care, to decrease the risk of urinary retention, and voiding complications. Urinary retention is common whilst in hospital for hip surgery. If not properly identified and managed, there is a high risk of complications, some lifelong and life threatening. Although evidence-based guidelines are available, the implementation is lagging.

METHODS

Twenty orthopaedic sites are cluster randomised into intervention and control sites, respectively. The intervention sites assemble local facilitator teams among nursing and rehabilitation staff, including first-line managers. The teams receive a 12-month support programme, including face-to-face events and on-demand components to map and bridge barriers to guideline implementation, addressing leadership behaviours and de-implementation of unproductive routines. All sites have access to the guidelines via a public healthcare resource, but the control sites have no implementation support. Baseline data collection includes structured assessments of urinary retention procedures via patient records, comprising incidence and severity of voiding issues and complications, plus interviews with managers and staff, and surveys to all hip surgery patients with interviews across all sites. Further assessments of context include the Alberta Context Tool used with staff, the 4Ps tool for preference-based patient participation used with patients, and data on economic aspects of urinary bladder care. During the implementation intervention, all events are recorded, and the facilitators keep diaries. Post intervention, the equivalent data collections will be repeated twice, and further data will include experiences of the intervention and guideline implementation. Data will be analysed with statistical analyses, including comparisons before and after, and between intervention and control sites. The qualitative data are subjected to content analysis, and mixed methods are applied to inform both clinical outcomes and the process evaluation, corresponding to a hybrid design addressing effectiveness, experiences, and outcomes.

DISCUSSION

The OPTION trial has a potential to account for barriers and enablers for guideline implementation in the orthopaedic context in general and hip surgery care in particular. Further, it may progress the understanding of implementation leadership by dyads of facilitators and first-line managers.

TRIAL REGISTRATION

The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021, that is, prior to the baseline data collection.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review

PURPOSE

Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management.

METHODS

We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed.

RESULTS

The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h.

CONCLUSIONS

This review provided an up-to-date guide for the detection and management of POUR.

LEVEL OF EVIDENCE

Level III.

Analysis of Risks and Consequences of Postcatheter Urinary Retention After Primary Total Hip and Knee Arthroplasty

Background

Postoperative urinary retention (POUR) in total joint arthroplasty (TJA) is common. However, risk factors for POUR and its consequences, specifically on postoperative renal function, have not been well defined.

Methods

We performed a review of prospectively collected data on consecutive adult patients undergoing primary total joint arthroplasty from August 2014 to December 2015. Catheters were placed preoperatively and removed on the first or second postoperative day. The exclusion criterion was traumatic catheter insertion or the presence of fracture or neoplasm. Univariate and multiple logistic regression identified associations with POUR and its invasive therapies. Subgroup analysis of renal function by incidence of preoperative bladder outlet obstruction (BOO) and POUR was performed with nonparametric testing.

Results

A total of 591 operations met inclusion criteria. The incidence of POUR was 6.4% and was directly related to a positive history of BOO (odds ratio [OR]: 4.15) and increased the duration of urinary catheterization (OR: 1.04). These factors, in addition to preoperative incontinence (OR: 8.36, 28.69) and lengthier hospitalizations (OR: 1.37, 1.30), were significantly associated with intermittent straight catheterization and reinsertion of an indwelling catheter to treat POUR. Serum creatinine increased with combined preoperative BOO and POUR (+0.22 mg/dL) but was preserved in others (+0.02-0.04 mg/dL) (P < 0.01).

Conclusions

Preoperative BOO and longer catheterization increased the risk of POUR and were associated with the use of invasive modalities to treat POUR. POUR was associated with a longer hospitalization and impaired renal function in those with preoperative BOO; therefore, renal function should be monitored closely and nephrotoxic medications used cautiously when using urinary catheters in this patient population.

Level of Evidence

Retrospective Analysis, Level IV.

Anticipating Urinary Retention Following Total Hip and Total Knee Replacements

Introduction

Urinary retention is a widely recognised postoperative complication. Although anecdotally lower limb arthroplasty is linked with high rates of urinary retention, there are no current accepted standards for determining which patients are at higher risk and should therefore be offered intra operative catheterisation.

Materials and Methods

One hundred patients, 55 females and 45 males, who underwent uncomplicated total hip or total knee replacements at Furness General Hospital were recruited between January and April 2017.

Results

Post-operative urinary retention was seen frequently, with 38 patients (38%) requiring post-operative catheterisation. Twenty-one males (46%) developed postoperative retention compared to 17 (30%) of females, representing a statistically significant increase in risk seen in male patients. (p 0.009). Post-operative urinary retention requiring catheterisation was associated with increasing age, with those over 75 years having a significantly higher risk than those less than 75 years irrespective of gender (p 0.04). There was no significant difference in urinary retention rates between patients who had general (n=21) or spinal anaesthetic (n=79) with 33% of GA patients and 39% of spinal anaesthetic patients requiring catheterisation (p 0.17).

Conclusion

There are increased rates of urinary retention seen in lower limb arthroplasty patients than those described in the general surgical population, with male patients and all those over 75 years of age having a significantly higher risk. Clinically, it may therefore be sensible to consider offering routine intra operative catheterisation to this cohort of patients.

Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery

Postoperative urinary retention (POUR) may result from orthopaedic procedures and potentially lead to bacteremia and chronic voiding difficulties. Risk factors for POUR include age, undergoing joint arthroplasty, male sex, intraoperative intravenous fluid administration, operative time, and history of benign prostatic hyperplasia. Indwelling catheterization is the preferred management strategy for patients at risk for developing POUR. A consistent definition of POUR is needed in order to draw conclusions from future studies.

[Risk factors for postoperative indwelling catheter following enhanced recovery after total knee arthroplasty]

Objective

To evaluate the risk factors for postoperative indwelling catheter following enhanced recovery after primary unilateral total knee arthroplasty (TKA) under general anesthesia.

Methods

Patients who underwent primary unilateral TKA under general anesthesia between January 2017 and August 2018 were enrolled in the study. Among them, 205 patients who met the selection criteria were included in the study, and the clinical data were collected, including gender, age, body mass index, preoperative range of motion, Hospital for Special Surgery (HSS) score, American Society of Anesthesiologists (ASA) score, disease type, comorbidity, hemoglobin, hematocrit, blood volume, length of operation and operation time, whether to keep drainage after surgery, intraoperative blood loss, total blood loss, and preoperative, intraoperative, postoperative fluid infusions, and total fluid infusion on the day of surgery, urine volume on the day of surgery. Univariate analysis and logistic regression analysis were used to screen the risk factors for postoperative indwelling catheter. Length of stay and incidences of complications (intermuscular vein thrombosis, deep vein thrombosis, pulmonary embolism, incision swelling and exudation, electrolyte disorder, nausea and vomiting, and urinary tract infection) were compared between the patients with or without indwelling catheter.

Results

Indwelling catheter occurred in 41 (20%) of 205 patients. Single factor analysis showed that the influence factors were age, gender, keeping drainage after surgery, total fluid infusion and urine volume on the day of surgery ( P<0.05). The multiple factors analysis showed that the males and more urine volume on the day of surgery were the significant risk factors for indwelling catheter after primary TKA ( P<0.05). In addition, postoperative length of stay was shorter and the incidence of urinary tract infection was lower in non-indwelling catheter group than in indwelling catheter group, showing significant differences ( P<0.05).

Conclusion

The male patients with more urine on the day of surgery have higher risk for indwelling catheter after primary unilateral TKA under general anesthesia with an enhanced recovery program.

Would early removal of indwelling catheter effectively prevent urinary retention after hip fracture surgery in elderly patients?

BACKGROUND

This study aimed to investigate the incidence and risk factors of postoperative urinary retention (POUR) among elderly patients who underwent hip fracture surgery and to evaluate the effect of indwelling catheterization on the occurrence of POUR.

MATERIALS AND METHODS

From January 2012 to January 2015, consecutive patients aged over 70 years who underwent hip fracture surgery were enrolled in this study. All patients underwent indwelling catheterization due to voiding difficulty upon admission. Demographic data, perioperative variables, and postoperative duration of patient-controlled analgesia and indwelling catheterization, postoperative complications, and mortality were collected. The incidence of POUR was investigated, and the risk factors related to POUR were analyzed using a logistic regression analysis. The cutoff value for the timing of catheter removal was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

POUR developed in 68 patients (31.8%) of the 214 patients. Of these, 24 (35.3%) were male. The indwelling catheter was left in place for an average of 3.4 days (range, 0-7 days) postoperatively. A significant difference was noted in gender and duration of indwelling catheterization between patients with POUR and without. The cutoff value for the timing of catheter removal as determined by ROC curve analysis was 3.5 postoperative day with 51.4% sensitivity and 71.5% specificity. Multiple logistic regression revealed that the duration of the indwelling catheter [odds ratios (OR), 0.31; p = 0.016)] and male gender (OR, 2.22; p = 0.014) were independent risk factors related to the occurrence of POUR.

CONCLUSIONS

The significant risk factors of POUR among elderly patients undergoing hip fracture surgery were early indwelling catheter removal and male gender. Therefore, early removal of indwelling catheter in elderly patients following hip fracture surgery may increase the risk of POUR, especially in male patients.

Identifiable Risk Factors to Minimize Postoperative Urinary Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) following total joint arthroplasty (TJA) presents a significant barrier to outpatient and early discharge TJA. This study examined the incidence and risk factors for acute POUR in a modern, evidence-based, outpatient, and early discharge TJA program.

METHODS

Prospectively recorded data on 685 consecutive primary unilateral TJAs discharged the day of or day after surgery were retrospectively reviewed. POUR was diagnosed by a perioperative internal medicine specialist. Univariate analysis of potential predictors was performed, followed by binary logistic regression (BLR) testing of predictors with P ≤ .25.

RESULTS

After exclusions for confounds, the final analysis sample consisted of 633 procedures. The overall incidence of POUR was 5.5% (3.9% for same day discharges). Male gender, history of urinary retention, use of rocuronium, use of glycopryrrolate, use of neostigmine, fentanyl spinals, and the absence of an indwelling urethral catheter were associated with acute POUR and met criteria for entry into multivariate BLR. Seventeen additional predictors, including kidney disease and outpatient surgery were unrelated to POUR. In the final BLR model (P = .001), male patients who received glycopyrrolate with neostigmine had a 34% probability of developing POUR, which declined to 2.8% in the absence of these risk factors.

CONCLUSION

Despite a relatively low incidence of 5.5%, avoidance of anticholinergics and cholinesterase inhibitors during anesthesia should be carefully considered in outpatient TJA, particularly in stand-alone ambulatory surgery centers.

The AAHKS Clinical Research Award: Prophylactic Tamsulosin Does Not Reduce the Risk of Urinary Retention Following Lower Extremity Arthroplasty: A Double-Blinded Randomized Controlled Trial

BACKGROUND

Postoperative urinary retention (POUR) is common. Selective alpha-1 adrenergic antagonists, such as tamsulosin, are effective for treating urinary retention. The purpose of this study is to determine whether perioperative prophylactic tamsulosin reduces the incidence of POUR following total hip and knee arthroplasty.

METHODS

Male patients 35 years of age and older undergoing primary total hip or knee arthroplasty at a single center from 2015 to 2018 were eligible for inclusion. Patients were randomized to receive tamsulosin 0.4 mg or placebo daily for 5 days preoperatively, the morning of surgery, and the first postoperative day. The incidence of POUR was determined during the postoperative hospitalization.

RESULTS

A total of 176 patients were enrolled in the study. Two patients were withdrawn prior to randomization. The remaining 174 were randomized to tamsulosin (n = 87) or placebo (n = 87). After an additional 43 patients were withdrawn prior to surgery, 131 patients completed the study (tamsulosin, n = 64; placebo, n = 67). A total of 42 patients (32.1%) developed POUR, with 18 cases (28.1%) in the tamsulosin group and 24 cases (35.8%) in the placebo group (P = .345), resulting in an odds ratio of 0.701 and a risk difference of 7.69%.

CONCLUSION

Prophylactic tamsulosin did not reduce the incidence of POUR after hip and knee arthroplasty compared to placebo. The odds ratio indicates an approximately 30% decreased odds of developing POUR in the tamsulosin group, albeit not statistically significant. Tamsulosin does not appear to be effective as a prophylactic measure for reducing POUR in male hip and knee arthroplasty patients.

Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial

Background

The purpose of this study was to investigate whether patients undergoing total joint arthroplasty (TJA) require catheterization.

Methods

PubMed, EMBASE, Web of Science, Cochrane Library and China National Knowledge Infrastructure were systematically searched. All randomized controlled trials (RCTs) receiving either a urinary catheterization or no urinary catheterization were included. Meta-analysis results were assessed by RevMan 5.3 software.

Results

Seven independent RCTs were included, with a total sample size of 1533 patients, including 750 patients in the indwelling catheter group and 783 patients in the none-indwelling catheter group. Our pooled data analysis indicated that patients in the indwelling catheter group had a higher risk of urinary tract infection than patients in the none-indwelling catheter group (RR, 3.21; P = 0.0003). However, the meta-analysis indicated that there was no significant difference between the two groups in terms of urinary retention (RR, 0.67; P = 0.13), duration of the surgery (MD, − 0.37; P = 0.55), and length of hospital stay (MD, 0.15; P = 0.38).

Conclusion

Based on the current evidence, this meta-analysis showed that urinary catheterization during TJA can increase the postoperative urinary tract infection, and it may not routinely be required for the patients undergoing TJA.

Level of evidence

Level I, therapeutic study.

The Most Significant Risk Factors for Urinary Retention in Fast-track Total Joint Arthroplasty are Iatrogenic

BACKGROUND

Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay.

METHODS

Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors.

RESULTS

One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001).

CONCLUSION

The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged.

Bladder training prior to urinary catheter removal in total joint arthroplasty. A randomized controlled trial

BACKGROUND

Urinary catheters are commonly used in patients undergoing total hip and knee arthroplasty. Bladder training before catheter removal is reported to shorten the time to return to normal bladder function and reduce the incidence of urinary retention.

OBJECTIVE

To evaluate the results of bladder training in patients with total hip and knee arthroplasty.

DESIGN

Randomized controlled trial.

SETTING

Orthopaedic Department of a tertiary Military Hospital.

PARTICIPANTS

We enrolled consecutive patients undergoing total hip or knee arthroplasty during a period of 14 months.

METHODS

We randomly allocated the participants into either a bladder training group, in which clamping was considered prior to catheter removal, or a free drainage removal group, using a computer-generated list and subsequently assessed their need for re-catheterization due to urinary retention. The primary outcome of this study was to evaluate if bladder training in patients with total hip and knee arthroplasty reduces the need for re-catheterization due to urinary retention. Multivariable logistic regression was used to model the association between postoperative urinary retention and independent variables (total hip or total knee arthroplasty, age, gender, and history of diabetes mellitus or prostatism). Secondary outcomes were the incidence of urinary tract infection, and subjective patients' symptoms.

RESULTS

We included 218 patients in the study; 114 in the bladder training group and 104 in the free drainage removal group. All patients were over 50 years old with a mean age of 69.3 (SD = 8) years. We observed three cases of urinary retention in the bladder training and six in free drainage removal group, and the difference was not statistically significant (2.6% and 5.8% respectively, p = 0.316). We also observed increased odds of re-catheterization in patients with prostatism under medication (odds ratio was 26.42, p < 0.001). No infections or major subjective symptoms were noted.

CONCLUSION

This trial shows that bladder training by catheter clamping offers no advantage over free draining removal of short-term urinary catheters in patients with total hip and knee arthroplasty. Therefore, we conclude that the bladder training procedure is not indicated. However, healthcare providers should monitor patients' urination after removal of the catheter.

Incidence and Risk Factors of Postoperative Urinary Retention and Bladder Catheterization in Patients Undergoing Fast-Track Total Joint Arthroplasty: A Prospective Observational Study on 371 Patients

BACKGROUND

Postoperative urinary retention (POUR) appears to be a common complication in lower limb joint arthroplasty; however, reports on its incidence vary. There is no general consensus on its definition and there is no scientific evidence on treatment principles. We performed a prospective observational study to establish the incidence of POUR and its risk factors, including the preoperative postvoid residual urine volume and the perioperative fluid balance, in fast-track total joint arthroplasty (TJA). The preoperative residual urine volume and the perioperative fluid balance have not been studied in previous literature in the context of TJA and POUR.

METHODS

Three hundred eighty-one patients who underwent TJA of the lower limb were observed on developing POUR according to our local treatment protocol. Data on possible risk factors for POUR were collected including the perioperative fluid balance and the preoperative residual urine volume.

RESULTS

In total, 46.3% of patients were catheterized. A preoperative postvoid urine retention is a significant predictor of catheterization for postoperative residual urine (P = .03). Spinal anesthesia was correlated with urinary retention (P = .01). There was no cause-effect relationship between POUR and the perioperative fluid balance.

CONCLUSION

This study underlines POUR as a common complication in fast-track lower limb arthroplasty, with spinal anesthesia as a risk factor. A higher preoperative residual urine volume leads to higher postoperative residual volume, but not to a higher change in urinary retention. Increased perioperative fluid administration is not correlated with the incidence of POUR. Furthermore, there seems to be little rationale for monitoring residual urine volume both preoperatively and postoperatively.

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia

BACKGROUND

The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia.

METHODS

Consecutive patients who underwent a primary THA without preoperative catheterization under spinal anesthesia were identified in a prospectively collected institutional patient database. All patients were monitored postoperatively for urinary retention on the basis of symptoms and the use of bladder ultrasound scans performed by a hospital technician. If necessary, straight catheterization was performed up to 2 times prior to indwelling catheter insertion.

RESULTS

One hundred eighty patients were included in the study. Six patients who required indwelling catheterization for intraoperative monitoring were excluded. Seventy-six patients experienced POUR and required straight catheterization. Fourteen patients ultimately required indwelling catheterization. One patient who was not catheterized developed a urinary tract infection versus none of the patients who were catheterized. POUR was significantly associated with intraoperative fluid volume and a history of urinary retention (P = .018 and .023, respectively). Intraoperative fluid volumes of 2025, 2325, 2875, and 3800 mL were associated with a specificity for POUR of 60%, 82.7%, 94.9%, and 98%, respectively. No significant associations were found among catheterization and gender, body mass index, American Society of Anesthesiologists class, history of polyuria, history of incontinence, postoperative oral narcotics use, or surgical duration.

CONCLUSION

Patients with a history of prior urinary retention and those who receive high volumes of intraoperative fluid volume are at higher risk for POUR following THA performed under spinal anesthesia.

Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty: A Randomized, Open-label, Controlled Trial

BACKGROUND

No evidence-based threshold exists for postoperative urinary bladder catheterization. The authors hypothesized that a catheterization threshold of 800 ml was superior to 500 ml in reducing postoperative urinary catheterization and urological complications after fast-track total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

This was a randomized, controlled, open-label trial that included patients greater than or equal to 18 yr who underwent THA or TKA in three Danish, fast-track, orthopedic departments. Consenting patients were eligible if they were cooperative and understood Danish. Participants were randomly allocated to a catheterization threshold of 500 or 800 ml, using opaque sealed envelopes. Group assignment was unmasked. Ultrasound bladder scans were performed every second hour until the first voluntary micturition, with subsequent urinary catheterization according to group assignment. The primary outcome was the number of patients catheterized before their first voluntary micturition. Thirty-day telephonic follow-up was on voiding difficulties, urinary tract infections, and readmissions.

RESULTS

Of 800 patients allocated, 721 (90%) were included in a per-protocol analysis (20 did not complete the study and 59 were excluded from the analysis). In the 500-ml group, 32.2% received catheterization (114 of 354) compared to 13.4% (49 of 367) in the 800-ml group (relative risk, 0.4; 95% CI, 0.3 to 0.6; P < 0.0001). The authors found no difference between groups in any secondary outcome.

CONCLUSIONS

In fast-track THA and TKA, a catheterization threshold of 800 ml significantly reduced the need for postoperative urinary catheterization, without increasing urological complications. This large randomized, controlled trial may serve as a basis for evidence-based guidelines on perioperative urinary bladder management.

Discontinuation of peri-operative gentamicin use for indwelling urinary catheter manipulation in orthopaedic surgery

BACKGROUND

Gentamicin has historically been used prior to insertion and removal of indwelling urinary catheters (IDCs) around elective joint replacement surgery to prevent infection; however, this indication is not recognized in the Australian Therapeutic Guidelines: Antibiotic and the paradigm for safe use of gentamicin has shifted.

METHODS

The antimicrobial stewardship team of a 500 bed tertiary regional hospital performed a retrospective clinical study of gentamicin IDC prophylaxis around total hip and knee arthroplasties. Results were presented to the orthopaedic surgeons. A literature review identified no guidelines to support gentamicin prophylaxis and only a very low risk of bacteraemia associated with IDC insertion/removal in patients with established bacteriuria. Consensus was reached with the surgeons to discontinue this practice. Subsequent prospective data collection was commenced to determine effectiveness, with weekly feedback to the Department Head of Orthopaedics.

RESULTS

Data from 137 operations pre-intervention (6 months) were compared with 205 operations post-intervention (12 months). The median patient age was 72 years in both groups. Following the intervention, reductions in gentamicin use were demonstrated for IDC insertion (59/137 (42%) to 4/205 (2%), P < 0.01) and removal (39/137 (28%) to 6/205 (3%), P < 0.01). No gentamicin use was observed during the final 40 weeks of the post-intervention period. There were no significant differences between the groups for pre-operative bacteriuria, surgical site infections or acute kidney injury.

CONCLUSION

A collaborative approach using quality improvement methodology can lead to an evidence-based reappraisal of established practice. Regular rolling audits and timely feedback were useful in sustaining change.

Factors influencing the choice of anesthetic technique for primary hip and knee arthroplasty

Despite evidence in the literature, continuing wide variation exists in anesthetic technique for primary joint arthroplasties. Recent evidence suggests that neuraxial anesthesia has advantages over general anesthesia in terms of mortality, major morbidity and healthcare utilization. Yet, despite the proposed benefits, utilization of these two techniques varies greatly across geographical locations, with general anesthesia being most common for total hip arthroplasty (THA) and total knee arthroplasty (TKA) in parts of the world. We uncover some factors that promote or hinder the use of neuraxial anesthesia in THA and TKA. Healthcare professionals should be familiarized with the evidence for neuraxial anesthesia, and unbiased educational material should be developed for patients regarding anesthetic options for THA and TKA in order to promote best practice.

Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder Measurement

BACKGROUND

In this study, we sought to determine whether a simplified ultrasound measurement of the largest transverse diameter, using a standard ultrasound machine, could be used to diagnose postoperative urinary retention (POUR). This method may replace expensive bladder volume measuring devices or a more complex ultrasound procedure (involving the measurement of 3 bladder diameters).

METHODS

Patients at risk of POUR if unable to void after orthopedic surgery were evaluated in the postanesthesia care unit before discharge. Bladder diameter was first measured using a portable ultrasound device (Vscan®; GE Healthcare, Wauwatosa, WI). An automated evaluation of bladder volume was then performed (Bladderscan® BVI 3000; Diagnostic Ultrasound, Redmond, WA). Finally, when a bladder catheterization was performed, the actual urinary volume was measured. The main outcome was a bladder volume ≥600 mL as measured using the automated ultrasound scanner (Bladderscan BVI 3000) or by catheterization. Correlations between bladder volumes and diameter were studied and receiver operating characteristic curves were constructed to determine the performance in predicting a bladder volume ≥600 mL. A "gray zone" approach was developed because a single cutoff value may not always be clinically significant.

RESULTS

One hundred patients were included and underwent a Bladderscan measurement. Urinary volume after catheterization was obtained in 49 patients. A significant correlation was found between the largest transverse diameter and urinary volumes assessed by the 2 methods (Bladderscan and catheterization). Pearson correlation coefficients were r = 0.80 (95% confidence interval [CI], 0.72-0.86; P < 0.001) and r = 0.79 (95% CI, 0.65-0.88; P < 0.001), respectively. The area under the receiver operating characteristic curves for the prediction of a bladder volume ≥600 mL were 0.94 (95% CI, 0.88-0.98) and 0.91 (95% CI, 0.79-0.97), respectively, for urinary volumes assessed by Bladderscan and catheterization. The optimal cutoff value was 9.7 cm for both methods. The gray zone was narrow, ranging from 9.7 to 10.7 cm thus limiting inconclusive measurements.

CONCLUSIONS

A simple ultrasound measurement of the largest transverse bladder diameter seemed to be helpful to exclude or confirm POUR.

Urinary Retention is Rare After Total Joint Arthroplasty When Using Opioid-Free Regional Anesthesia

BACKGROUND

Postoperative urinary retention (POUR) is a relatively common complication after total joint arthroplasty (TJA). Based on the findings of a randomized, prospective study from our institution, we abandoned the routine use of indwelling urinary catheters in patients undergoing elective TJA using opioid-free spinal anesthesia. The aim of this study was to determine the incidence of and the risk factors for POUR in this patient population.

PATIENTS AND METHODS

A total of 842 consecutive patients underwent TJA between January 2012 and September 2014 using opioid-free spinal anesthesia in whom indwelling urinary catheters were not used. Postoperative urinary retention was defined as the inability of a patient to void that necessitated the placement of either an indwelling urinary catheter or straight catheterization. Multivariate logistic regression analysis was used to determine risk factors for developing POUR.

RESULTS

In this cohort, 79 patients (79/842; 9.3%) developed POUR. Independent risk factors for POUR were history of a benign prostatic hyperplasia (P = .02), renal disease (P = .001), longer operative time (P = .003), and age older than 67 years (P = .02). No patients in this cohort developed neurogenic bladder.

CONCLUSION

This study confirms that the routine use of indwelling urinary catheters for patients undergoing TJA using an opioid-free spinal anesthesia may not be warranted. Urinary catheters may be used selectively in patients at risk for subsequent urinary retention.

Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Objective

The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.

Methods

We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity.

Results

Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01).

Conclusions

Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively.

Level of Evidence

Level I.

Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty

Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb. In total hip arthroplasty and total knee arthroplasty, the incidence ranges from 7% to 84%. In this study, the incidence and risk factors for postoperative urinary retention were described in a cohort of 376 men undergoing total hip arthroplasty. Postoperative urinary retention was defined as the inability to void after surgery for which single or indwelling catheterization was performed. Risk factors were identified using multivariate regression analysis. Following total hip arthroplasty, 150 (39.9%) of the 376 men developed urinary retention. Patient-controlled analgesia (odds ratio, 4.10; 95% confidence interval, 1.79-9.40), use of spinal anesthesia (odds ratio, 1.79; 95% confidence interval, 1.07-2.99), and age 70 years or older (odds ratio, 1.77; 95% confidence interval, 1.06-2.95) were independent risk factors for urinary retention. Potential risk factors that were not confirmed included body mass index, American Society of Anesthesiologists physical status (Class I-III), hypertension, diabetes mellitus, prostate pathology, smoking, average pain during the first 24 hours after surgery, and length of surgery. Two of the 150 patients with urinary retention (1.3%) for which a catheter has been inserted developed a urinary tract infection vs none of the patients without urinary retention. The risk of urinary retention after total hip arthroplasty is increased in men older than 70 years, those receiving spinal anesthesia, and those with patient-controlled analgesia postoperatively.

Incidence of and risk factors for postoperative urinary retention in fast-track hip and knee arthroplasty

BACKGROUND AND PURPOSE

Postoperative urinary retention (POUR) is a clinical challenge, but there is no scientific evidence for treatment principles. We describe the incidence of and predictive factors for POUR in fast-track total hip (THA) and knee arthroplasty (TKA).

PATIENTS AND METHODS

This was a prospective observational study involving 1,062 elective fast-track THAs or TKAs, which were performed in 4 orthopedics departments between April and November 2013. Primary outcome was the incidence of POUR, defined by postoperative catheterization. Age, sex, anesthetic technique, type of arthroplasty, and preoperative international prostate symptom score (IPSS) were compared between catheterized and non-catheterized patients.

RESULTS

The incidence of POUR was 40% (range between departments: 30-55%). Median bladder volume evacuated by catheterization was 0.6 (0.1-1.9) L. Spinal anesthesia increased the risk of POUR (OR = 1.5, 95% CI: 1.02-2.3; p = 0.04) whereas age, sex, and type of arthroplasty did not. Median IPSS was 6 in non-catheterized males and 8 in catheterized males (p = 0.02), but it was 6 in the females in both groups (p = 0.4).

INTERPRETATION

The incidence of POUR in fast-track THA and TKA was 40%, with spinal anesthesia and increased IPSS in males as predictive factors. The large variation in perioperative bladder management and in bladder volumes evacuated by catheterization calls for randomized studies to define evidence-based principles for treatment of POUR in the future.

Postoperative length of stay and 30-day readmission after geriatric hip fracture: an analysis of 8434 patients

OBJECTIVES

To identify factors associated with increased postoperative length of stay (LOS) and readmission after surgical repair of geriatric hip fractures.

METHODS

Patients aged 70 years and older who underwent hip fracture surgery from January 2011 through December 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with postoperative LOS and readmission using bivariate and multivariate analyses.

RESULTS

For the 8434 patients with hip fracture identified, the average age was 83.8 ± 5.9 years (mean ± SD), and 26.9% were male. Average postoperative LOS was 5.6 ± 6.0 days. Ten percent were readmitted within the first 30 postoperative days. Increased postoperative LOS of at least 1 full day was associated with increased time from admission to surgery, non-general anesthesia, and procedure type on multivariate analysis. Readmission was associated with increased age, male sex, body mass index ≥35 kg/m, American Society of Anesthesiologists class ≥3, pulmonary disease, hypertension, steroid use, dependent functional status, and discharge to a facility on multivariate analysis.

CONCLUSIONS

Ten percent of patients were readmitted after hip fracture repair in this national sample. Preoperative time to surgery, anesthesia type, and implant selection are 3 risk factors for increased LOS that can potentially be modified. A clinically significant risk factor for readmission was body mass index ≥35 kg/m, which was not associated with increased postoperative LOS. The identified risk factors illuminate opportunities for optimizing care for hip fracture patients aged 70 and older.

LEVEL OF EVIDENCE

Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

General anesthesia: to catheterize or not? A prospective randomized controlled study of patients undergoing total knee arthroplasty

This study was to investigate whether urinary catheterization could be avoided for patients undergoing total knee arthroplasty (TKA) under general anesthesia with saphenous nerve block. 314 patients from a single surgical team were randomized to receive either an indwelling urinary catheter or no urinary catheter before the surgery. The results revealed that the prevalence of postoperative urinary retention (POUR) was quite low in both groups (5.7% vs 6.4%, P=1). Additionally, the prevalence of urinary tract infection was significantly higher in patients using an indwelling catheter (5.1% vs 0.6%, P=0.036). We also identified age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of surgery as the risk factors for POUR in these patients.

The incidence of postoperative urinary retention in patients undergoing elective hip and knee arthroplasty

INTRODUCTION

Postoperative urinary retention requiring urethral catheterisation increases the risk of joint sepsis following arthroplasty. Spinal anaesthesia with opiate administration is used widely in lower limb arthroplasty. We sought to establish whether the choice of opiate agent had any effect on the incidence of postoperative retention and therefore the risk of joint sepsis.

METHODS

A total of 445 consecutive patients who underwent primary elective lower limb arthroplasty were reviewed retrospectively. Patients had general anaesthesia and femoral nerve block (GA+FNB), spinal anaesthesia and intrathecal fentanyl (SA+ITF) or spinal anaesthesia and intrathecal morphine (SA+ITM).

RESULTS

Urinary retention was observed in 14% of male and 2% of female patients with GA+FNB, 9% of male and 3% of female patients with SA+ITF, and 60% of male (p=0.0005) and 5% of female patients with SA+ITM. Men who experienced retention were older (68 vs 64 years, p=0.013) and had longer inpatient stays (6.7 vs 4.6 days, p=0.043). Fewer patients in the SA+ITM group required breakthrough analgesia (28% vs 58%, p=0.004). Concusions: The use of ITM in men significantly increases the incidence of urinary retention requiring urethral catheterisation and subsequently increases the risk of deep joint sepsis. Its use should be rationalised against the intended benefits and alternatives sought where possible.

Spinal anesthesia: should everyone receive a urinary catheter?: a randomized, prospective study of patients undergoing total hip arthroplasty

BACKGROUND

The objective of this randomized prospective study was to determine whether a urinary catheter is necessary for all patients undergoing total hip arthroplasty under spinal anesthesia.

METHODS

Consecutive patients undergoing total hip arthroplasty under spinal anesthesia were randomized to treatment with or without insertion of an indwelling urinary catheter. All patients received spinal anesthesia with 15 to 30 mg of 0.5% bupivacaine. The catheter group was subjected to a standard postoperative protocol, with removal of the indwelling catheter within forty-eight hours postoperatively. The experimental group was monitored for urinary retention and, if necessary, had straight catheterization up to two times prior to the placement of an indwelling catheter.

RESULTS

Two hundred patients were included in the study. There was no significant difference between the two groups in terms of the prevalence of urinary retention, the prevalence of urinary tract infection, or the length of stay. Nine patients in the no-catheter group and three patients in the catheter group (following removal of the catheter) required straight catheterization because of urinary retention. Three patients in the catheter group and no patient in the no-catheter group had development of urinary tract infection.

CONCLUSIONS

Patients undergoing total hip arthroplasty under spinal anesthesia appear to be at low risk for urinary retention. Thus, a routine indwelling catheter is not required for such patients.

Enhanced care for primary hip arthroplasty: factors affecting length of hospital stay

BACKGROUND

Enhanced care in joint replacement requires identification and correction of the causes of delay in discharge while ensuring practice remains safe. We conducted prospective studies of factors delaying discharge following hip replacement in 2006 and 2010.

METHODS

Daily data were twice collected prospectively in 100 consecutive unselected primary cemented THR, by an independent observer. Reasons for delays in discharge and variation from the patient pathway were identified and addressed.

RESULTS

The mean length of stay (LOS) in 2006 was 4.3 days and in 2010, 3.56 days (target for discharge 4 days). In 2006, 31 patients had a stay of more than 4 days, 17 due to inadequate physiotherapy provision, 10 for medical and 4 for other reasons. In 2010, 15 patients had a stay of more than 4 days, 1 patient had inadequate physiotherapy provision, in 7 cases discharge was delayed because of need for blood transfusion and 7 because of need for catheterisation. Women aged more than 70 with preoperative haemoglobin of <12 g/dL were at particularly high risk of requiring transfusion. Catheterisation was also identified as a factor causing significant increase in LOS. Patients going home in less than 4 days were more likely to have had their operation in the morning.

CONCLUSION

Patient LOS is multifactorial and can be reduced by regular review of the care pathway to effect incremental changes that have a significant impact on reducing stay.

Association between low admission Norton scale scores and postoperative complications after elective THA in elderly patients

The Norton scoring system is used by nurses to evaluate pressure ulcer risk. The authors have previously shown that low admission Norton scale scores (ANSS) are associated with postoperative complications other than pressure ulcers following hip fracture and spine fracture surgery in elderly patients. The purpose of this retrospective, cross-sectional study study was to determine whether low ANSS are associated with postoperative complications other than pressure ulcers following elective total hip arthroplasty (THA) in elderly patients. The medical charts of consecutive elderly (older than 65 years) patients admitted between February 2008 and November 2010 were studied for acute renal failure, cardiovascular events, confusion, pneumonia, pressure ulcers, urinary infection, urinary retention, venous thromboembolism, wound infection, and other complications. The final cohort included 166 patients (108 [65.1%] women; aged 75.2±6.4 years). Overall, 24 (14.5%) patients had low (16 or less) ANSS. Patients with low ANSS had significantly more postoperative complications other than pressure ulcers compared with patients with high ANSS (0.5±0.7 vs 0.2±0.4, respectively; P=.018). Binary regression analysis showed that low ANSS were independently associated with all postoperative complications other than pressure ulcers (P=.039). In addition to predicting pressure ulcer risk, the Norton scoring system may be used for predicting other postoperative complications in elderly patients following elective THA.