Hip and Knee Arthroplasty

Safety of blood reinfusion drains after local infiltration analgesia in total joint replacement

BACKGROUND

Local infiltration analgesia (LIA) is frequently administered to patient undergoing joint replacement surgical procedures. The aim of the present research was to verify the safety of collected shed blood to be reinfused postoperatively, by measuring levobupivacaine levels in drainage blood in patients undergoing LIA during knee replacement surgery.

PATIENTS AND METHODS

24 patients who underwent total knee arthroplasty (TKA) and 12 scheduled for total hip arthroplasty (THA) who received intraoperative LIA were considered. Blood samples were collected from shed blood which was present in drainage 2 and 5 hours after surgery and serum was analysed by liquid chromatography-tandem mass spectrometry.

RESULTS

At 2 hours postoperatively, the median levobupivacaine serum concentration in the collected shed blood was 1.2 mg/L (SD: 4.2) for TKA and 17.13 mg/L (SD: 24.4) for THA. At 5 hours, levobupivacaine concentration was 1.84 mg/L (SD: 2.2) for TKA and 17.5 mg/L (SD: 25.2) for THA. Higher values of average serum levobupivacaine concentration were reported in drains collected from patients who had undergone THA compared to TKA (p<0.001). BMI significantly influenced levels of serum drug, that resulted to be higher in patients with BMI<25 (p= 0.01).

CONCLUSION

Levobupivacaine from collected shed blood that would have been returned to the patient, was below toxicity level at 2 and 5 hours after LIA during total joint replacement. The average serum levobupivacaine concentration was found to be higher in drains taken from THA patients than TKA patients. Patients with lower BMI demonstrated the highest levels of levobupivacaine in shed blood and a lower blood volume needed for central nervous system toxicity. Therefore, in patients with a lower BMI undergoing THA, anaesthetic dosage should be reduced or autotransfusion should be avoided to prevent potential risks of toxicity.

Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients

STUDY DESIGN/SETTING

A retrospective observational study.

OBJECTIVE

The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient.

SUMMARY OF BACKGROUND DATA

Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion.

MATERIALS AND METHODS

Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h).

RESULTS

In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management.

CONCLUSIONS

Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.

A Comprehensive Research on the Prevalence and Evolution Trend of Orthopedic Surgeries in Romania

Accurate knowledge of the prevalence and trends of orthopedic surgeries can facilitate the design of medical plans for effective treatments. The National Endoprosthetic Registry (NER) in Romania provides statistics on endoprosthetic activity (hip, knee), cases of fractures and bone tumors as a result of the legal obligations to report interventions performed by all orthopedic traumatology hospitals/wards in the country. The aim of this study is to describe the annual volumes of orthopedic surgeries between 2001 and 2022 in Romania and analyze the current and future evolution trends of the studied surgeries, gender differences and regional differences based on a complete survey carried out at a national level. For the period 2001-2022, we extracted from the NER the annual volumes of orthopedic interventions performed. With these data, we studied the prevalence and estimated, with the support of an original calculation methodology, the variation trends of orthopedic surgeries in two situations: over the entire 21-year period, respectively, and over the period 2001-2020, which does not include the pandemic period. For hip replacement surgery and knee replacement surgery, we showed the prevalence by subcategory of interventions, gender distribution, regional prevalence and regional density calculated by the annual averages of the total number of cases reported per 100,000 people in the 40 counties of the country and the capital, Bucharest. We also determined the variations in hip and knee arthroplasty revision burdens, calculated as a percentage between the number of revisions and the number of primary interventions in the same period. We determined the regional densities of revision burdens. The total number of orthopedic surgeries in the period 2001-2022 was 1,557,247, of which 189,881 were hip replacement surgeries; 51,035 were knee replacement surgeries; 11,085 were revision hip arthroplasty; 1497 were revision knee arthroplasty; 541,440 were operated fractures; and 16,418 were operated bone tumors. The growth rates of surgical interventions are hip replacement surgery, +8.19%; knee replacement surgery, +19.55%; revision hip arthroplasty, +9.43%; and revision knee arthroplasty, +28.57%. With these data, we have estimated a doubling of the volume of primary and revision interventions of the hip until 2034 and the knee until 2027, respectively. Operated bone tumors register an annual decrease of -4.52% thanks to modern treatments. There are clear gender differences; for primary hip interventions, the proportion of women is 58.82%, and for knee interventions, the proportion of women is 76.42%. This is the first research that, with the support of exhaustive data from the NER, analyzes for the period 2001-2022 the annual number of orthopedic surgeries in Romania. It allows knowledge of the large, anticipated increases in orthopedic surgery and provides a quantitative basis for future policy decisions related to the need for medical personnel and material resources.