Factors independently associated with complications and length of stay after hip arthroplasty: analysis of the National Surgical Quality Improvement Program

The learning curve for robotic-assisted total hip arthroplasty in low, medium, and high-volume surgeons

Background

Robotic systems have been designed to increase the accuracy of implant alignment in total knee and hip arthroplasty. This technology is associated with a learning curve for the operative time to reach peak efficiency in its use. Prior studies done on high-volume orthopedic surgeons have suggested a learning curve of 14-35 cases for robotic-assisted total hip arthroplasty (THA). It is unclear if this learning curve is different for surgeons with lower volumes.

Methods

Data was collected retrospectively from 299 THA procedures done by three different surgeons, with low (1-15 cases/year), medium (16-50), and high (51+) volume caseload. The learning curve was assessed primarily by average operative time from cases 1-20, 21-50, and 51+.

Results

The high-volume surgeon had a learning curve of 20 cases, while the low and medium volume surgeons had no significant decrease in their operative time through the cases included in the study (20 and 63, respectively).

Conclusions

High volume surgeons have a learning curve of about 20 cases, while low and medium volume surgeons have a longer curve, which was not able to be measured in this study.

Early Postoperative Functional Recovery in Older Patients With Periprosthetic Femoral Fractures: Comparison Between Cemented and Cementless Stem Revisions

Background

Early postoperative functional recovery is important in older patients with lower-extremity fractures to prevent disuse, and periprosthetic femoral fractures (PFFs) are no exception. This study aimed to compare the postoperative functional recovery in the early phase after revision for PFF with loose stems between cemented and cementless stems.

Methods

Eighteen patients with Unified Classification System type B2 PFF were included in this retrospective cohort study with a follow-up period of about 2 years. All patients underwent stem revision and were divided into 2 groups: the cemented stem group (n = 9) and the cementless stem group (n = 9). In postrevision, functional independence measure score, independent walk rate, activities of daily living recovery rate to the original level at 2 weeks postoperatively, the Beals and Tower classification for radiological status, and survival rate for readmission as endpoints were compared between the 2 groups.

Results

Patients in the cemented group recovered functional mobility earlier than in the cementless group, with higher postoperative functional independence measure functional subscale values (73 vs 50 points, P = .02), higher independent walk rate (89 vs 11%, P < .01), and more postoperative activities of daily living recovery (100% vs 44%, P = .03) at 2 weeks postoperatively. The Beals and Tower classification and survival rates were similar in both groups.

Conclusions

Revision using a cemented stem for PFF in older patients was a useful surgical procedure in terms of early postoperative functional recovery. Cemented stem revision was comparable with cementless in bone union and safety at 2 years postoperatively.

Association between diabetes mellitus and total hip arthroplasty outcomes: an observational study using the US National Inpatient Sample

OBJECTIVES

To investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA).

DESIGN

Retrospective cohort study using data from the US National Inpatient Sample (NIS).

SETTING

Study cohort was hospitalisations for primary THA in the USA, identified from the 2016-2020 NIS.

PARTICIPANTS

We identified 2 467 215 adults in the 2016-2020 NIS who underwent primary THA using International Classification of Diseases, 10th Revision codes. Primary THA hospitlizations were analysed as the overall group and also stratified by the underlying primary diagnosis for THA.

OUTCOME MEASURES

Outcome measures of interest were the length of hospital stay>the median, total hospital charges>the median, inpatient mortality, non-routine discharge, need for blood transfusion, prosthetic fracture, prosthetic dislocation and postprocedural infection, including periprosthetic joint infection, deep surgical site infection and postprocedural sepsis.

RESULTS

Among 2 467 215 patients who underwent primary THA, the mean age was 68.7 years, 58.3% were female, 85.7% were white, 61.7% had Medicare payer and 20.4% had a Deyo-Charlson index (adjusted to exclude diabetes mellitus) of 2 or higher. 416 850 (17%) patients had diabetes. In multivariable-adjusted logistic regression in the overall cohort, diabetes was associated with higher odds of a longer hospital stay (adjusted OR (aOR) 1.38; 95% CI 1.35 to 1.41), higher total charges (aOR 1.11; 95% CI 1.09 to 1.13), non-routine discharge (aOR 1.18; 95% CI 1.15 to 1.20), the need for blood transfusion (aOR 1.19; 95% CI 1.15 to 1.23), postprocedural infection (aOR 1.62; 95% CI 1.10 to 2.40) and periprosthetic joint infection (aOR 1.91; 95% CI 1.12 to 3.24). We noted a lack of some associations in the avascular necrosis and inflammatory arthritis cohorts (p>0.05).

CONCLUSION

Diabetes was associated with increased healthcare utilisation, blood transfusion and postprocedural infection risk following primary THA. Optimisation of diabetes with preoperative medical management and/or institution of specific postoperative pathways may improve these outcomes. Larger studies are needed in avascular necrosis and inflammatory arthritis cohorts undergoing primary THA.

Varying Complication Rates and Increased Costs in Technology-Assisted Total Hip Arthroplasty Versus Conventional Instrumentation in 1,372,300 Primary Total Hips

BACKGROUND

The use of technology allows surgeons increased precision in component positioning in total hip arthroplasty (THA). The objective of this study was to compare (1) perioperative complications and (2) resource utilizations between robotic-assisted (RA) and computer-navigated (CN) versus conventional instrumenttaion (CI) THA.

METHODS

A retrospective cohort study was performed using a large national database to identify patients undergoing unilateral, primary elective THA from January 1, 2016 to December 31, 2019 using RA, CN, or CI. There were 1,372,300 total patients identified and included RA (29,735), CN (28,480), and CI (1,314,085) THA. Demographics, complications, lengths of stay, dispositions, and costs were compared between the cohorts. Binary logistic regression analyses were performed.

RESULTS

The use of RA THA led to lower rates of intraoperative fracture (0.22% versus 0.39%), delirium (0.1% versus 0.2%), postoperative anemia (14.4% versus 16.7%), higher myocardial infarction (0.13% versus 0.08%), renal failure (1.7% versus 1.6%), blood transfusion (2.0% versus 1.9%), and wound dehiscence (0.02% versus 0.01%) compared to CI THA. The use of CN led to lower rates of respiratory complication (0.5% versus 0.8%), renal failure (1.1% versus 1.6%), blood transfusion (1.3% versus 1.9%), and pulmonary embolism (0.02% versus 0.1%) compared to CI THA. Total costs were increased in RA ($17,729 versus $15,977) and CN ($22,529 versus $15,977). Lengths of hospital stay were decreased in RA (1.8 versus 1.9 days) and CN (1.7 versus 1.9 days).

CONCLUSIONS

Perioperative complication rates vary in technology-assisted THA, with higher rates in RA THA and lower rates in CN THA, relative to CI THA. Both RA THA and CN THA were associated with more costs, shorter postoperative hospital stays, and higher rates of discharge home compared to CI THA.

Weighing the Impact: The Influence of Body Mass Index on Facility Costs in Total Joint Arthroplasty

BACKGROUND

Using time-driven activity-based costing (TDABC), a novel cost calculation method that more accurately reflects true resource utilization in health care, we sought to compare the total facility costs across different body mass index (BMI) groups following total joint arthroplasty (TJA).

METHODS

The study consisted of 13,806 TJAs (7,340 total knee arthroplasties [TKAs] and 6,466 total hip arthroplasties [THAs]) performed between 2019 and 2023. The TDABC data from an analytics platform was employed to depict total facility costs, comprising personnel and supply costs. For the analysis, patients were stratified into four BMI categories: <30, 30 to <35, 35 to <40, and ≥40. Multivariable regression was used to determine the independent effect of BMI on facility costs.

RESULTS

When indexed to patients who had BMI <30, elevated BMI categories (30 to <35, 35 to <40, and ≥40) were associated with higher total personnel costs (TKA 1.03x versus 1.07x versus 1.13x, P < .001; THA 1.00x versus 1.08x versus 1.08x, P < .001), and total supply costs (TKA 1.01x versus 1.04x versus 1.04x, P < .001; THA 1.01x versus 1.02x versus 1.03x, P = .007). Total facility costs in TJAs were significantly greater in higher BMI categories (TKA 1.02x versus 1.05x versus 1.08x, P < .001; THA 1.01x versus 1.05x versus 1.05x, P < .001). Notably, when incorporating adjustments for demographics and comorbidities, BMI values of 35, 40, and 45 relative to BMI of 25, exhibit a significant association with a 2, 3, and 5% increase in total facility cost for TKAs and a 3, 5, and 7% increase for THAs.

CONCLUSIONS

Using TDABC methodology, this study found that overall facility costs of TJAs increase with BMI. The present study provides patient-level cost insights, indicating the potential need for reassessment of physician compensation models in this population. Further studies may facilitate the development of risk-adjusted procedural codes and compensation models for public and private payors.

LEVEL OF EVIDENCE

Level IV, economic and decision analyses.

Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population

BACKGROUND

Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations.

METHODS

Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression.

RESULTS

Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients.

CONCLUSION

Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA.

LEVEL OF EVIDENCE

III.

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study

BACKGROUND

The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries.

METHODS

Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors.

RESULTS

The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs.

CONCLUSIONS

This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Perioperative safety and efficacy of robot-assisted total hip arthroplasty in ERAS-managed patients: a pilot study

AIMS

Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients.

METHODS

In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications.

RESULTS

The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P < 0.001). No significant differences were observed between the rTHA and cTHA groups for blood loss parameters, including total blood loss (1280.30 ± 404.01 vs. 1094.86 ± 494.39 ml, P = 0.137) and drainage volume (154.35 ± 121.50 vs. 159.13 ± 135.04 ml, P = 0.900), as well as intraoperative blood loss (126.67 ± 38.80 vs. 118.52 ± 60.68 ml, P = 0.544) and hidden blood loss (982.43 ± 438.83 vs. 784.00 ± 580.96 ml, P = 0.206). Only one patient in the cTHA group required allogeneic blood transfusion. At 3 months postoperatively, both groups showed improvements in WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, and Harris score, with no significant differences found between the two groups. Few complications were reported in both groups without significant differences.

CONCLUSIONS

Despite the longer surgical time, rTHA did not negatively affect blood loss, pain, or functional recovery or lead to an increased risk of complications in ERAS-managed patients, suggesting that rTHA can be safely and effectively incorporated into an ERAS program for primary THA.

Impact of Large Database Studies on Orthopedic Surgery Literature: Are We Advancing the Field?

Background: While database studies have become more prevalent in the literature, there is concern over their value. In addition, the questions they are suitable to answer are limited. Questions/Purposes: We sought to determine the incidence of database studies in the orthopedic literature and in each subspecialty. In addition, we wanted to assess the impact of database studies on the literature by determining whether citations and Altmetric Attention Scores (AAS) varied by study type (studies using internal or external databases and those not using databases). Methods: We searched PubMed for articles published in impactful orthopedic surgery journals in the year 2018. All articles were discoverable on the Altmetric explorer portal database. Impact was determined by journal impact factor. Study design, subspecialty, number of citations, and AAS were obtained. Univariable analyses were conducted between study type, demographic variables, and the outcome of either citation count or AAS. Multivariable analyses were performed to identify independent predictors of the primary outcomes. Subgroup analyses were performed to differentiate the impact of external and internal database studies compared with non-database studies. Results: A total of 2684 total articles were eligible for inclusion. Of these, 366 studies (13.6%) were database studies. Hip and knee articles had the greatest incidence of database studies. Database studies had significantly more citations (5.9 vs 4.0) and significantly higher AAS (12.8 vs 11.3) compared with non-database studies. External database studies had significantly more citations (6.7 vs 4.8) and significantly higher AAS (14.0 vs 10.7) than internal database studies. Internal database studies had higher traditional citation counts but similar AAS to non-database studies. Conclusions: In 2018, database studies in well-reputed orthopedic journals had a greater number of citations but similar AAS compared with non-database studies. Further studies are warranted.

Defining Prolonged Length of Stay (PLOS) Following Elective Laparoscopic Cholecystectomy and Derivation of a Preoperative Risk Score to Inform Resource Utilization, Risk Stratification, and Patient Consent

OBJECTIVE

The present study defines prolonged length of stay (PLOS) following elective laparoscopic cholecystectomy (LC) and its relationship with perioperative morbidity. A preoperative risk tool to predict PLOS is derived to inform resource utilization, risk stratification and patient consent.

BACKGROUND

Surgical candidates for elective LC are a heterogeneous group at risk of various perioperative adverse outcomes. Preoperative recognition of high-risk patients for PLOS has implications on feasibility for day surgery, resource utilization, preoperative risk stratification, and patient consent.

METHODS

Data for all patients who underwent elective LC between January 2015 and January 2020 across 3 surgical centers (1 tertiary referral center and 2 satellite units) in 1 health board were collected retrospectively (n=2166). The optimal cut-off of PLOS as a proxy for operation-related adverse outcomes was found using receiver operating characteristic curves. Multivariate logistic regression was conducted on a derivation subcohort to derive a preoperative model predicting PLOS. Receiver operating characteristic curves were performed to validate the model. Patients were stratified by the risk tool and the risks of PLOS were determined.

RESULTS

A LOS of ≥3 days following elective LC demonstrated the best diagnostic ability for operation-related adverse outcomes [area under curve (AUC)=0.87] and defined the PLOS cut-off. The rate of PLOS was 6.6% (144/2166), 86.1% of which had a perioperative adverse outcome. PLOS was strongly associated with all adverse outcomes (subtotal, conversion-to-open, intraoperative complications, postoperative complication/imaging/intervention) ( P <0.001). The preoperative model demonstrated good diagnostic ability for PLOS in the derivation (AUC=0.81) and validation cohorts (AUC=0.80) and stratified patients appropriately.

CONCLUSIONS

Morbidity in PLOS patients is significant and pragmatic patient selection in accordance with the risk tool may help centers improve resource utilization, risk stratification, and their consent process. The risk tool may help select candidates for cholecystectomy in a strictly ambulatory/outpatient center.

The ABLE Anterior-Based Muscle-Sparing Approach: A Safe and Effective Option for Total Hip Arthroplasty

Background

The direct anterior and posterior approaches are well-researched options in total hip arthroplasty (THA). The less-studied anterior-based muscle-sparing approach, also known as the ABLE advanced anterior approach, centers on minimizing surgical trauma and medical costs while maintaining or improving patient outcomes.

Material and methods

THAs performed using the ABLE approach by 3 surgeons at a single institution between January 2013 and August 2020 were retrospectively assessed for outcomes pertaining to safety and performance intraoperatively, perioperatively, and postoperatively. Additionally, intraoperative and postoperative complications were evaluated, and patient-reported outcome measures and radiographic outcomes out to 1-year follow-up.

Results

There were 6251 THAs (5433 patients) eligible for inclusion. The mean surgical time was 65 minutes, mean intraoperative blood loss was 204 mL, and the transfusion rate was 0.5%. Patients had a mean length of stay of 1.4 days. Overall, 93.4% of patients were discharged home, 1.9% visited the emergency department within 30 days, and 2.9% had an unplanned readmission to the hospital within 90 days. The overall major surgical complication rate was 1.18%, with a dislocation rate of 0.13%, a deep infection rate of 0.19%, and a postoperative periprosthetic fracture rate of 0.37%.

Conclusions

The minimally invasive ABLE approach is a safe and effective surgical approach for patients undergoing THA. It can be performed efficiently and with limited complications, making it an appealing option for surgeons to utilize during this era of value-based care.

Total Joint Arthroplasty at a Novel “Hyperspecialty” Ambulatory Surgical Center With Extended Care Suites is as Safe as Inpatient Arthroplasty

Background

New “hyperspecialty” ambulatory surgical centers (HASCs) have been introduced to deliver safe and cost-efficient care, allowing patients to spend additional nights in an extended care suite before discharge. This study compared the 90-day complications and readmissions of total joint arthroplasty (TJA) at an HASC and inpatient TJA at a tertiary hospital.

Methods

We retrospectively reviewed 1365 primary, unilateral, TJAs (658 total hip arthroplasty, 707 total knee arthroplasty) performed at 4 HASCs in 2017-2021. Following their outpatient procedure, patients were discharged to an extended care suite staffed full-time by nurses and physical therapists. These patients were matched 1:1 with 1365 inpatient TJAs (628 total hip arthroplasty, 737 total knee arthroplasty) based on demographics, joint, and American Society of Anesthesiologists (ASA) score. Ninety-day complications and readmissions were compared.

Results

The mean age was 60.0 ± 9.8 years and 59.4 ± 8.1 years in the inpatient and outpatient groups, respectively (P = .106). There was no difference in ASA≥3 patients (16.4% vs 17.7%; P = .387) and operative time (86.9 ± 31.8 vs 88.7 ± 27.9 minutes; P = .118). Five patients (0.4%) in the outpatient group were transferred to an acute hospital. When comparing 90-day outcomes between the inpatient and outpatient groups, there was no difference in pulmonary embolism (0.1% vs 0.0%; P = .317), mechanical complications (0.3% vs 0.7%; P = .165), periprosthetic joint infections (0.5% vs 1.1%; P = .092), or readmissions (1.2% vs 1.5%; P = .513). A subgroup analysis of ASA≥3 patients yielded similar findings.

Conclusions

Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital. Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4.

Adverse Events Associated With Robotic-Assisted Joint Arthroplasty: An Analysis of the US Food and Drug Administration MAUDE Database

BACKGROUND

The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes.

METHODS

Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact.

RESULTS

Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn.

CONCLUSION

Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects.

Increased length of stay following total joint arthroplasty based on insurance type

BACKGROUND

Increased length of stay after total joint arthroplasty has been shown to be a risk factor for peri-operative complications. The purpose of this study was to determine if Medicaid insurance would be a risk factor for increased length of stay after total joint arthroplasty.

METHODS

We retrospectively reviewed a single surgeon's practice of 428 total hip and total knee arthroplasties who had insurance status of Medicaid, Medicare, Private or none. After exclusion criteria there were 400 patients. Patients with insurance status of Medicaid, Medicare or Private were then compared based on length of stay ≤ 2 days and length of stay > 2 days and then further analyzed using demographic, operative data, and total length of stay.

RESULTS

Medicaid patients had an increased length of stay compared to patients with Medicare or Private insurance [1.98 days versus 1.73 days, p = .037, 95% confidence intervals (1.78-2.18) and (1.61-1.85), respectively]. The greatest predictor of a less than two-night stay post-operatively was private insurance status (p = 0.001). Medicaid patients had a higher incidence of prescribed narcotic use pre-operatively (p = 0.013). Although not significant, a trend was noted in the Medicaid population with higher incidence of smoking (p = 0.094) and illicit drug abuse (p = 0.099) pre-operatively in this sample subset.

CONCLUSIONS

Patients with Medicaid insurance undergoing total joint arthroplasty have increased length of stay compared to patients with Medicare or Private insurance and have higher incidence of pre-operative narcotic use.

Outcome and cost analysis of primary total knee arthroplasty in end-stage renal disease patients: A nationwide population-based study

BACKGROUND

A number of patients with end-stage renal disease (ESRD) undergo total knee arthroplasty (TKA) due to advanced knee joint osteoarthritis. There are few studies describing the incidence, morbidities, mortality rate, and cost analysis regarding ESRD patients receiving TKA.

METHODS

We retrospectively retrieved patient data from National Health Insurance Research Database in Taiwan during 2005-2011, and evaluated the outcomes of TKA in patients with (ESRD group) and without ESRD (non-ESRD group). Patients' demographic data, comorbidities, mortality, and in-hospital cost were recorded.

RESULTS

A total of 578 TKAs and 110,895 TKAs were identified in the ESRD and non-ESRD group, respectively. The incidence of patients receiving TKA was higher in the ESRD than in non-ESRD group by at least 2 folds. The ESRD group showed significantly more medical complications (pneumonia, peptic ulcer disease, and acute myocardial infarction) after surgery. In prosthesis-related complications, the ESRD group also had more periprosthetic joint infections, and prosthetic loosenings by one year. The one-year mortality rate was more than 6 times higher in the ESRD than in the non-ESRD group. The ESRD group had higher in-hospital medical expense than the non-ESRD group, especially when there were complications, even when the dialysis-related costs were exempted.

CONCLUSION

The complication rate, mortality rate, and cost were higher in the ESRD patients receiving TKA. When considering TKA in ESRD patients, it is crucial to weigh the risks against benefits of TKA, and have a thorough discussion with the patients.

Comparing early and mid-term outcomes between robotic-arm assisted and manual total hip arthroplasty: a systematic review

The projected increase in utilization rates of total hip arthroplasty (THA) has created an emphasis on novel technologies that can aid providers in maintaining historically positive outcomes. Widespread utilization of robotic assisted THA (RA-THA) is contingent upon achieving favorable outcomes compared to its traditional manual counterpart (mTHA). Therefore, the purpose of our systematic review was to compare RA-THA and mTHA in terms of the following: (1) functional outcomes and (2) complication rates. The PubMed, Embase, and Cochrane library databases were searched for articles published October 1994 and May 2021 comparing functional outcomes and complication rates between RA-THA and mTHA cohorts. When three or more studies evaluated certain PROMs and complications, a pooled analysis utilizing Mantel-Haenszel (M-H) models was conducted utilizing data from final follow-up. Our final analysis included 18 studies which reported on a total of 2811 patients [RA-THA: n = 1194 (42.48%); mTHA: n = 1617 (57.52%)]. No significant differences were demonstrated for a majority of pooled analyses and when segregating by robotic system. Only WOMAC scores were significantly lower among RA-THA patients (p = 0.0006). For outcomes without sufficient data for a pooled analysis, there were no significant differences reported among included studies. The growing utilization of RA-THA motivates comparisons to its manual counterpart. Collectively, we found comparable functional outcomes and complication profiles between RA-THA and mTHA cohorts. More randomized controlled trials of higher quality and larger sample sizes are necessary to further strengthen these findings.

Preoperative Anemia in Primary Arthroplasty Patients-Prevalence, Influence on Outcome, and the Effect of Treatment

BACKGROUND

This study aims to: 1) Determine the prevalence of preoperative anemia in arthroplasty; 2) Assess whether preoperative anemia is associated with inferior outcomes; and 3) Ascertain whether optimization in a dedicated blood management program (BMP) is associated with improved outcomes.

METHODS

All primary arthroplasties performed at an academic, tertiary-care, arthroplasty center between 2012 and 2017 were reviewed. Hemoglobin level obtained in the preoperative assessment clinic was recorded. Patients with anemia were then considered for further review in BMP. Outcomes included improvement in hemoglobin level post-BMP; length of stay; perioperative transfusion; 90-day readmission, complication, and reoperation rates. The effect of preoperative anemia and the effect of treatment at the BMP on outcomes were evaluated through multivariable regression analysis controlling for relevant covariates.

RESULTS

17% of patients (932/5384) were found to have anemia; 115/357 patients who attended the BMP were no longer anemic. Thus, at time of operation, 15% of patients (817/5384) had anemia. Anemic patients were 4.09 times more likely (95% CI: 2.64-6.35) to require a transfusion; 1.42 times more likely (95% CI: 0.99-2.03) to sustain complications and had 19% longer (95% CI: 13%-26%) length of stay. Those who attended the BMP were less likely to receive a transfusion (OR = 0.32, 95% CI: 0.16-0.66), suffer from postoperative complications (OR = 0.30, 95% CI: 0.14-0.63), or require readmission compared with anemic patients not seen in the BMP (OR = 0.25, 95% CI: 0.09-0.71).

CONCLUSIONS

The prevalence of anemia in this arthroplasty cohort was 15%. Preoperative, timely, optimization of anemia should be strongly considered as it is likely to reduce "anemia-associated burden" after arthroplasty.

An Argument for the Safety of Immediate Device Reconstruction following Mastectomy during the COVID-19 Crisis

Although oncologic surgery is deemed urgent during the COVID-19 pandemic, clinical guidelines in reconstructive surgery have been unclear. Utilizing propensity-matched pre-pandemic data and our institutional experience during the crisis, we aimed to assess the safety of immediate device reconstruction following mastectomy to aid in decision-making during the pandemic.

Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach

BACKGROUND

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure.

METHODS

Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT.

RESULTS

A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R² of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001).

CONCLUSIONS

We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.

Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry

Background

Total hip and total knee arthroplasty (THA/TKA) are increasing in incidence annually. While these procedures are effective in improving pain and function, there is a risk of complications.

Methods

Using data from an arthroplasty registry, we described complication rates including reasons for reoperation and readmission from the acute period to six months following THA and TKA in an Australian context. Data collection at 6 months was conducted via telephone interview, and included patient-reported complications such as joint stiffness, swelling and paraesthesia. We used logistic regression to identify risk factors for complications.

Results

In the 8444 procedures included for analysis, major complications were reported by 9.5 and 14.4% of THA and TKA patients, respectively, whilst minor complications were reported by 34.0 and 46.6% of THA and TKA patients, respectively. Overall complications rates were 39.7 and 53.6% for THA and TKA patients, respectively. In THA patients, factors associated with increased risk for complications included increased BMI, previous THA and bilateral surgery, whereas in TKA patient factors were heart disease, neurological disease, and pre-operative back pain and arthritis in a separate joint. Female gender and previous TKA were identified as protective factors for minor complications in TKA patients.

Conclusion

We found moderate rates of major and high rates of minor postoperative complications following THA and TKA in Australia and have identified several patient factors associated with these complications. Efforts should be focused on identifying patients with higher risk and optimising pre- and post-operative care to reduce the rates of these complications.

Why Do Patients Stay Longer Than Three Nights Following Hip and Knee Arthroplasty?

BACKGROUND

Prolonged length of stay (PLOS) is frequently cited by secondary data studies as an adverse outcome following hip and knee arthroplasty. Although perhaps indisputable that PLOS increases the cost of hospitalization, it is unknown whether it is an appropriate measure of the quality of an arthroplasty procedure.

METHODS

We searched our institution's database for all hip and knee arthroplasty procedures over a 5-year period using MS-DRG (Medicare Severity-Diagnosis Related Group) 469 and 470. Cases with greater than 3 night stays were identified. Charts were manually reviewed by 2 independent reviewers to identify the primary reason for PLOS, and the need for 30-day readmission or reoperation.

RESULTS

Of a total 4347 hip and knee arthroplasty cases, 218 (5.0%) were identified with LOS greater than 3 nights. The majority of prolonged stays were due to exclusively medical reasons (81 cases: 37.2%; 95% confidence interval [CI] 31.0-43.7). The second most common cause was inpatient days prior to the arthroplasty procedure (45 cases: 20.6%; 95% CI 15.8-26.5). Orthopedic reasons for PLOS were significantly less common than medical reasons (36 cases: 16.5%; 95% CI 12.2-22.0, P < .0001), most often due to failure to meet therapy goals. Neither readmission (31 cases: 14.2%) nor reoperation (10 cases: 4.6%) was associated with an underlying reason for PLOS.

CONCLUSION

When evaluating LOS as a measure of quality of an arthroplasty procedure, readers of secondary "big data" studies should be aware that there are significant limitations to its utility. Even after controlling for potential confounders, we found that PLOS does not necessarily reflect an adverse outcome.

Have Total Hip Arthroplasty Operative Times Changed Over the Past Decade? An Analysis of 157,574 Procedures

BACKGROUND

With the recent reevaluation of surgeon reimbursement for total hip arthroplasty (THA) by the Centers for Medicare and Medicaid Services, there is increasing need for information regarding trends in operative time. While single-institutional analyses exist, there is a lack of large-scale, nationally representative, multi-institutional data. Therefore, the purpose of our study is to (1) evaluate past/present operative time trends for THA and (2) investigate factors influencing operative times from a 10-year, large multi-institutional database.

METHODS

All primary THAs conducted between 2008 and 2018 were queried using Current Procedural Terminology code 27130 from the American College of Surgeons-National Surgical Quality Improvement Program database, yielding 157,574 patients. Operative time, demographics, and comorbidity data were collected and analyzed. Multivariable linear models were created, and trend analyses were used where appropriate.

RESULTS

Median operative time was 87 minutes. Operative time was stable across included study years, with all calculated values within 5 minutes of the median (range, 86-92 minutes). Operative time was statistically stable over the last 3 years (P = .121). Age, body mass index, resident involvement, modified Charlson comorbidity index, and preoperative laboratory values influenced operative time (P < .001). Length of stay, readmission, superficial wound infection, and sepsis decreased over the study period. Nonelective procedures were statistically longer than elective (P < .0001).

CONCLUSION

While numerous factors influence the duration of THA, this study found that THA operative time has remained stable in recent years. Therefore, revaluation for THA based on intraservice time is not supported. Future analyses should continue to analyze factors that influence operative time in order to ensure patient safety and maintain positive outcomes.

Is surgical duration associated with postoperative complications in primary shoulder arthroplasty?

BACKGROUND

Surgical duration is an independent predictor of short-term adverse outcomes after a variety of orthopedic procedures, both arthroscopic and open. However, this association in shoulder arthroplasty remains unclear. The purpose of this study was to identify the association between surgical duration and postoperative complications, as well as increased use of health care resources, after shoulder arthroplasty.

METHODS

Primary shoulder arthroplasty procedures performed from 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgical duration was divided into 3 cohorts: (1) surgical procedures lasting less than 90 minutes, (2) those lasting between 90 and 120 minutes, and (3) those lasting more than 120 minutes. Baseline patient characteristics and outcome variables were compared using bivariate analysis. Outcome variables were compared using multivariate analysis.

RESULTS

Overall, 14,106 patients were identified. Longer surgical duration was significantly associated with younger age, male patients, higher body mass index, and use of general anesthesia, (P < .001 for each), as well as smoking history (P < .39). Relative to operative times shorter than 90 minutes, surgical procedures lasting more than 120 minutes had higher rates of any complication (P = .002), return to the operating room (P = .008), urinary tract infection (P = .02), non-home discharge (P < .001), blood transfusion (P < .001), and unplanned 30-day hospital readmission (P = .03).

CONCLUSION

Increasing surgical duration was associated with a variety of postoperative medical complications and increased use of health care resources including discharge to acute care facilities, blood transfusions, and hospital readmission. These data suggest that surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors.

The effect of body mass index on 30-day complications after total hip arthroplasty

BACKGROUND

Evaluating body mass index (BMI) as a continuous variable eliminates the potential pitfalls of only considering BMI as a binary or categorical variable, as most studies do when correlating BMI and total hip arthroplasty (THA) outcomes. Therefore, the objective of this study was to correlate the effect of continuous BMI on 30-day complications post-THA. Specifically, we correlated BMI to: (1) 30-day readmissions and reoperations; (2) medical complications; and (3) surgical complications in: (a) normal-weight; (b) over-weight; (c) obese; and (d) morbidly obese patients.

METHODS

Using the NSQIP database, 93,598 primary THAs were identified. 30-day rates of readmissions, reoperations, and medical/surgical complications as well as patient BMI data were extrapolated. A comparative analysis using univariate, multivariate, and spline regression models adjusting for demographics and comorbidities were created to study the continuous effect of BMI on different outcomes.

RESULTS

Readmission (p < 0.001), reoperation (p = 0.007), superficial infection (p = 0.003), prosthetic joint infection (p < 0.001), and sepsis (p = 0.026) had a J-shaped relationship with BMI, with the lowest rates seen in patients with BMI around 28 kg/m². The risks of mortality (p = 0.007) and transfusion (p < 0.001) had a reverse J-shaped relationship, with the risk steadily decreasing for BMIs in the normal weight and overweight range, and then flattening afterwards.

CONCLUSION

This data proposes a multifactorial effect of BMI on post-THA complications. Considering BMI as a continuous variable allows for a better assessment when considering the interplay between modifiable risk factors, such as smoking or alcohol use, as well as multiple comorbidities.

Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA.

MATERIALS AND METHODS

We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis.

RESULTS

Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies.

CONCLUSIONS

These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required.

TRIAL REGISTRATION

PROSPERO CRD42019123776.

Length of Hospital Stay for Osteoarthritic Primary Hip and Knee Replacement Surgeries in New Zealand

This study aims to explore the length of stay (LOS) of publicly funded osteoarthritic primary hip and knee replacement surgeries in New Zealand. Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgery in 2005-2017 were included. We have identified 53,439 osteoarthritic primary hip replacements and 50,072 osteoarthritic primary knee replacements. LOS has been reduced by almost 40% over the last 13 years. Logistic regression showed that women, Māori, Pacific and Asian patients, older patients, people with more comorbidities and those having opiates on discharge and patients in earlier years were more likely to have extended LOS following hip replacements and knee replacements. Regional differences were noted in LOS between the Waitemata District Health Board (DHB) compared to Tairāwhiti DHB where patients were the most likely to have a LOS of more than 5 days after hip and knee replacements. LOS after hip and knee replacements has been reduced dramatically. Women, Māori, Pacific and Asian patients, older patients and people with more comorbidities are more likely to have extended LOS. Patients dispensed opiates on discharge had a longer LOS. There are great geographical variations in LOS for primary hip and knee surgeries in New Zealand.

Operative Times Have Remained Stable for Total Hip Arthroplasty for >15 Years: Systematic Review of 630,675 Procedures

Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period.

METHODS

The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were "operative," "time," and "total hip arthroplasty." An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria.

RESULTS

The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee.

CONCLUSIONS

The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost.

Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study

BACKGROUND

In France and in the US, predictions for 2030 include an increased number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures together with an overall trend towards shorter hospital stays. Predictors of hospital length of stay (LOS) include the day of surgery, discharge destination, and patient comorbidities. Available data are conflicting, however, and to our knowledge predictors of LOS after THA or TKA have not been evaluated in France. Improved knowledge of these predictors would be expected to increase patient care efficiency. The objectives of this study were: (1) to determine whether the above-listed factors predict LOS after THA or TKA, (2) to identify predictors of discharge to a rehabilitation unit and of readmission within 30 days after surgery.

HYPOTHESIS

Both patient-related factors unamenable to modification and modifiable organisational factors are associated with LOS after THA or TKA.

MATERIAL AND METHODS

This large single-centre retrospective cohort study included all adults who underwent primary THA or TKA at our university hospital between 1 January 2015 and 31 December 2016. Non-inclusion criteria were revision arthroplasty, THA with femoral or acetabular reconstruction, TKA using a constrained hinged implant, and fracture as the reason for arthroplasty. Preoperative parameters, type of arthroplasty, and postoperative care were recorded.

RESULTS

We included 938 patients with THA and 725 patients with TKA. By multivariate analysis, the likelihood of being discharged by day 5 decreased with older age (HR, 0.986; 95%CI: 0.98-0.99) and was lower by 13% in females (HR, 0,871; 95%CI: 0.77-0.986), by 39% in patients with diabetes (HR, 0.606; 95%CI: 0.5-0.73), by 68% in patients discharged to rehabilitation units (HR, 0.322; 95%CI: 0.267-0.389), and by 27% in patients who had arthroplasty on a Friday (HR, 0.733; 95%CI: 0.631-0.852). Factors predicting discharge to rehabilitation unit were older age, female gender, chronic obstructive pulmonary disease, anxiety-depressive disorder, and a history of stroke. Risk factors for 30-day readmission were male gender, obesity, and discharge to rehabilitation unit.

DISCUSSION

In this study, predictors of LOS were identified using a survival model that considered age as a continuous variable, separate comorbidities, and the discharge destination. Our findings are consistent with earlier reports and confirm the strong associations linking LOS to diabetes, day of surgery, and discharge destination in France. We also identified predictors of discharge to rehabilitation and of readmission within 30 days.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

The Effect of Body Mass Index on 30-day Complications After Revision Total Hip and Knee Arthroplasty

BACKGROUND

We aimed to explore the effect of body mass index (BMI) on 30-day complications after aseptic revision total knee arthroplasty (rTKA) and aseptic revision total hip arthroplasty (rTHA), considering BMI as both a categorical and continuous variable.

METHODS

A total of 18,866 patients (9093 rTHA and 9773 rTKA) patients were included for analysis using the American College of Surgeons National Surgical Quality Improvement Project database. Thirty-day rates of readmissions, reoperations, and major and minor complications were compared between different weight categories (overweight: BMI >25 and ≤30 kg/m²; obese: BMI >30 and ≤40 kg/m²; morbidly obese: BMI >40 kg/m²) and the normal weight category (BMI >18.5 and ≤25 kg/m²) using multivariate regression models. Spline regression models were created to study BMI as a continuous variable.

RESULTS

Both readmission rates and reoperation rates increased for rTKA as BMI increased (P < .005). There was a linear relationship between BMI and readmission rates for rTKA. Morbid obesity was associated with an increased reoperation rate for rTHA on univariate analysis (P = .022); however, multivariate analysis showed no statistically significant increase in readmission or reoperation rates as BMI increased for rTHA.

CONCLUSIONS

The relationship between BMI and complications after revision total joint arthroplasty is a J-shaped curve with the lowest rates of complications occurring around a BMI of 30 kg/m². The relationship between BMI and perioperative complications is stronger for revision TKA as opposed to revision THA.

An Evaluation of the Safety and Effectiveness of Total Hip Arthroplasty as an Outpatient Procedure: A Matched-Cohort Analysis

BACKGROUND

Outpatient hip arthroplasty is being performed more routinely; however, safety remains a concern. The purpose of this study was to compare the rate of adverse events of outpatient total hip arthroplasty (THA) and assess barriers to discharge.

METHODS

We examined 136 patients who underwent unilateral THA by one surgeon and were discharged on the same day of surgery. Using propensity matching, 136 inpatients who received the same procedure, and were discharged on postoperative day one or later, were identified. For each cohort, 90-day occurrence of adverse events, readmissions, and emergency visits were recorded and compared. Adverse events were graded using the OrthoSAVES tool. A secondary objective was to assess potential barriers to same-day discharge.

RESULTS

Within 90 days postoperatively, 12 outpatients (8.82%) and 14 inpatients (10.29%) developed an adverse event. There were no significant differences between the rate or severity of adverse events between the 2 groups and no serious adverse events in either group. In the outpatient group, there was a correlation between the dosage of spinal anesthetic (bupivacaine) given and time required to stay in postanesthetic care unit postoperatively.

CONCLUSION

When comparing the 2 groups, there were no differences in adverse events at 90 days. At our center, in the appropriate patient population, outpatient THA is a safe and cost-effective option. A potential barrier to mobility postoperatively and successful same-day discharge is the time required to stay in postanesthetic care unit postoperatively, which was significantly correlated with an increased dose of spinal anesthetic given in our outpatient cohort.

Prolonged operative duration is associated with complications: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types.

METHODS

An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria.

RESULTS

Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time.

CONCLUSIONS

Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.

Factors influencing postoperative length of stay in an enhanced recovery after surgery program for primary total knee arthroplasty

Background

Hospital length of stay (LOS) after primary total knee arthroplasty (TKA) has decreased obviously following the implementation of enhanced recovery after surgery (ERAS) program in the last few years. However, there are still some patients that cannot be discharged at early time for a variety of reasons, and it is necessary to explore factors leading to prolonged LOS. Therefore, the purpose of this study was to identify the complete preoperative, perioperative, and postoperative factors associated with prolonged postoperative LOS (PLOS) after primary TKA in a detailed ERAS program.

Methods

In a consecutive series from July 2015 to March 2017, all patients who underwent unilateral elective primary TKA were included in the retrospective study. A PLOS greater than 3 days was considered a prolonged PLOS. Multivariable logistic regression analysis was performed to identify patient characteristics and relevant preoperative, perioperative, and postoperative variables that were associated with prolonged PLOS and postoperative complications.

Results

A total of 241 patients were included with a mean PLOS of 3.8 days. Prolonged PLOS was significantly associated with preoperative valgus deformity of the knee (OR 4.95, 95%CI 1.56–15.77, P = 0.007), increased serum level of interleukin-6 on postoperative day 1 (OR 1.01, 95%CI 1.00–1.03, P = 0.039), increased visual analogue scale pain score and serum level of C-reactive protein on postoperative day 3 (OR 2.56, 95%CI 1.28–5.13, P = 0.008; OR 1.01, 95%CI 1.00–1.03, P = 0.019), increased day to achieve 90° active knee flexion after surgery (OR 2.19, 95%CI 1.27–3.79, P = 0.005), and postoperative wound complications (OR 8.58, 95%CI 2.10–35.03, P = 0.003) and other minor complications (OR 6.04, 95%CI 2.40–15.19, P < 0.001). Preoperative pulmonary infection (OR 2.75, 95%CI 1.20–6.28, P = 0.016), American Society of Anesthesiologists score 3/4 (OR 2.14, 95%CI 1.01–4.52, P = 0.046), and utilization of catheter after surgery (OR 2.53, 95%CI 1.23–5.19, P = 0.012) were significantly associated with postoperative complications.

Conclusions

Multiple factors were associated with prolonged PLOS and postoperative complications after TKA in the ERAS program. It is important to recognize all the factors to try to maximize the use of medical resources and ultimately optimize the care of our patients.

Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion

STUDY DESIGN

This is retrospective study of prospectively collected data.

OBJECTIVE

To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database.

SUMMARY OF BACKGROUND DATA

A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions.

RESULTS

A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2-5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032).

CONCLUSIONS

The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care.

LEVEL OF EVIDENCE

Level III.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur

BACKGROUND

The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible.

METHODS

We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities.

RESULTS

Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m² (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%).

CONCLUSION

A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.

Impact of Definition and Timeframe on Capturing Surgery-Related Readmissions After Primary Joint Arthroplasty

BACKGROUND

Readmission rate has emerged as an important metric to measure quality, but varying definitions and timeframes are used. We aimed to evaluate the impact of different readmission definitions (postoperative vs postdischarge) and timeframes (30 vs 90-day) on capturing surgery-related readmissions after primary total joint arthroplasty.

METHODS

Patients who underwent primary total hip or knee arthroplasty between January 1, 2013 and December 31, 2015 were included. The electronic medical records of readmitted patients were reviewed to determine whether a surgery-related event was most responsible for readmission. The performances of 4 definition-timeframe combinations in capturing surgery-related readmissions were evaluated.

RESULTS

A total of 2586 patients were included. Using both postoperative and postdischarge definitions, there were no differences in the proportion of readmissions that were surgery-related when comparing 30 and 90-day timeframes (postoperative: 71% vs 60%, P = .118; postdischarge: 68% vs 60%, P = .219). Greater proportion of readmissions between days 0 and 30 were for surgery-related reasons compared with readmissions between days 31 and 90 using both postoperative and postdischarge definitions (postoperative: 71% vs 47%, P = .005; postdischarge: 68% vs 49%, P = .022). Among 104 patients readmitted for surgery-related reasons within 1 year of discharge, 52% were readmitted within 30 days of surgery compared with 79% within 90 days (P < .001). Similarly, 53% and 81% of readmissions were captured by the 30 and 90-day postdischarge definitions, respectively (P < .001).

CONCLUSION

A 90-day timeframe is superior in capturing surgery-related readmissions after total joint arthroplasty. Important Total hip and knee arthroplasty adverse events may be missed using a 30-day timeframe.

What Should Define Preoperative Anemia in Primary THA?

BACKGROUND

The use of tranexamic acid (TXA) in THA decreases the risk of transfusion after surgery. However, nearly 10% of patients still undergo a transfusion, which has been independently associated with an increased risk of complications. Preoperative anemia has been proven to be a strong predictor of transfusion after THA, but the ideal "cutoff" values in today's population that maximize sensitivity and specificity to predict transfusion have yet to be established.

QUESTIONS/PURPOSES

(1) Which preoperative factors are associated with postoperative transfusion in the setting of TXA use? (2) If preoperative hemoglobin (Hgb) remains associated with transfusion, what are the best-supported preoperative Hgb cutoff values associated with increased transfusion after THA?

METHODS

A retrospective chart analysis was performed from January 1, 2013, to January 1, 2015, on 558 primary THAs that met prespecified inclusion criteria. A multivariable logistic regression analysis model was used to identify independent factors associated with transfusion. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative Hgb cut point across all participants, as well as adjusted by sex and TXA use. Overall, 60 patients with a blood transfusion were included and compared with 498 control subjects (11% risk of transfusion).

RESULTS

After controlling for potential confounding variables such as age, sex, American Society of Anesthesiologist score, intravenous TXA (IV TXA) use, and preoperative Hgb, we found that patients with lower preoperative Hgb (g/dL per 1-unit decrease, odds ratio [OR], 2.6; 95% CI, 2.0-3.5; p < 0.001), female sex (vs male, OR, 4.2; 95% CI, 1.7-10.3; p = 0.002), and those unable to receive IV TXA (topical TXA/no TXA, OR, 13.5; 95% CI, 6.3-28.6; p < 0.001) were more likely to receive a transfusion. Of these, preoperative Hgb was found to be the variable most highly associated with transfusion (AUC, 0.876). A preoperative Hgb cutoff value of 12.6 g/dL maximized the AUC (0.876) for predicting transfusion across all patients unadjusted for baseline characteristics (sensitivity = 83, specificity = 84) with values of 12.5 g/dL (sensitivity = 85, specificity = 77) and 13.5 g/dL (sensitivity = 92, specificity = 77) for women and men, respectively.

CONCLUSIONS

The 1968 WHO definitions of anemia (preoperative Hgb < 13 g/dL for men and < 12 g/dL for women) used currently may underestimate patients at risk of transfusion after THA today. Further studies are needed to see if blood conservation referral decreases the risk of transfusion with preoperative treatment of anemia.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Factors Associated with Adverse Events in Inpatient Elective Spine, Knee, and Hip Orthopaedic Surgery

BACKGROUND

Orthopaedic procedures for degenerative musculoskeletal conditions (predominantly osteoarthritis and spinal stenosis) represent an increasing burden on the health-care system. These procedures are also associated with adverse event rates and related cost. The objective of this study was to identify risk factors for adverse events associated with orthopaedic surgeries as captured within a common clinical point-of-care system for documenting adverse events (Orthopaedic Surgical AdVerse Events Severity [OrthoSAVES] system).

METHODS

In-hospital adverse events were recorded at the point of care over a 2-year period for inpatient elective knee, hip, and spine orthopaedic procedures for degenerative musculoskeletal conditions. Multivariable logistic regression was employed to investigate the association between various factors (age, sex, surgical site, body mass index, surgical risk classification, operative duration, length of stay, and medical comorbidities) and the occurrence of adverse events.

RESULTS

The sample included 2,146 patients. The overall adverse event rate was 27% (571 of 2,146), and by surgical site, the rates were 29% (130 of 442) for spine; 27% (266 of 998) for knee; and 25% (175 of 706) for hip. The most common adverse events had a low severity grade, but spinal procedures demonstrated more adverse events with a severity grade of ≥3. Increasing age (odds ratio [OR] = 1.21, 95% confidence interval [CI] =1.05 to 1.41, per 15-year interval), male sex (OR = 1.43, 95% CI =1.16 to 1.77), increasing operative duration (OR = 1.13, 95% CI = 1.03 to 1.23, per 30-minute increase), length of stay (OR = 1.13, 95% CI = 1.10 to 1.17, per day), and undergoing revision surgery (OR = 2.23, 95% CI = 1.35 to 3.70) were independently associated with a greater likelihood of the occurrence of an adverse event. Spine surgery demonstrated decreased odds of an adverse event compared with knee surgery (OR = 0.38, 95% CI = 0.23 to 0.61) when operative duration and length of stay were taken into account.

CONCLUSIONS

On the basis of our adjusted analysis, we found increasing age, male sex, revision surgery, length of stay, and increasing operative duration to be common independent risk factors for an adverse event across the population studied. The first 3 risk factors are not modifiable. The association between increasing operative duration and the risk of an adverse event across all anatomical regions and surgical procedures is a unique finding. However, modification of procedural efficiency is multifactorial and warrants further investigation.

LEVEL OF EVIDENCE

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

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty

BACKGROUND

Increased operative duration has been shown to have demonstrable effects on the outcomes and complications in multiple areas of orthopedic surgery. We sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. Our hypothesis was that increased surgeon and trainee volume would decrease operative times and that more complex pathology would increase operative duration.

METHODS

A retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015 was performed evaluating the correlation between specific patient and surgeon factors and operative duration. The influence of operative duration on postoperative length of stay and risk of readmission within 30 days was also analyzed.

RESULTS

For surgeon-specific factors, high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001). Progression through the fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001). Certain complex pathologic processes (reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery) showed increased operative times. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes).

CONCLUSIONS

Increased surgeon and trainee volumes were associated with decreased operative duration in shoulder arthroplasty. Patients with more complex pathology were more likely to have increased surgical times. Postoperative readmission within 30 days was associated with increased operative duration. Consideration of patient selection by surgeons to minimize operative times may reduce readmissions.

Should All Patients Be Included in Alternative Payment Models for Primary Total Hip Arthroplasty and Total Knee Arthroplasty?

BACKGROUND

Alternative payment models in total joint replacement incentivize cost effective health care delivery and reward reductions in length of stay (LOS), complications, and readmissions. If not adjusted for patient comorbidities, they may encourage restrictive access to health care.

METHODS

We prospectively evaluated 802 consecutive primary total hip arthroplasty and total knee arthroplasty patients evaluating comorbidities associated with increased LOS and readmissions.

RESULTS

During this 9-month period, 115 patients (14.3%) required hospitalization >3 days and 16 (1.99%) were readmitted within 90 days. Univariate analysis demonstrated that preoperative narcotic use, heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and liver disease were more likely to require hospitalization >3 days. In multivariate analysis, CKD and COPD were independent risk factors for LOS >3 days. A Charlson comorbidity index >5 points was associated with increased LOS and readmissions.

CONCLUSION

Patients with CKD, COPD, and Charlson comorbidity index >5 points should not be included in alternative payment model for THA and TKA.

Morbid Obesity in Total Hip Arthroplasty: Redefining Outcomes for Operative Time, Length of Stay, and Readmission

BACKGROUND

The incidence of obesity among patients presenting for elective total hip arthroplasty (THA) has increased in the last decade, and the relationship between obesity and the need for joint arthroplasty has been demonstrated. This study evaluates the effects of morbid obesity on outcomes after primary THA by comparing short-term outcomes in THA between a morbidly obese (body mass index [BMI] ≥40) and a normal weight (BMI, 18.5 to <25) cohort at our institution between January 2003 and December 2010.

METHODS

Thirty-nine patients included in the morbidly obese group were compared with 186 in the normal weight group. Operative time, length of stay, complications, readmission, and length of readmission were compared.

RESULTS

Operative time was increased in the morbidly obese group at 122 minutes compared with 100 minutes (P = .002). Postoperatively, there was an increased 30-day readmission rate related to surgery of 12.8% associated with BMI ≥40 compared with 2.7% (P = .005) as well as a 5.1-fold increase in surgery-related readmitted bed days-0.32 bed days per patient for normal weight compared with 1.64 bed days per patient for the morbidly obese (P = .026).

CONCLUSION

Morbidly obese patients present a technical challenge and likely this, and the resultant complications are underestimated. More work needs to be performed to enable suitable allocation of resources.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Morbid Obesity and Congestive Heart Failure Increase Operative Time and Room Time in Total Hip Arthroplasty

BACKGROUND

Obesity is increasingly common in patients having total hip arthroplasty, and previous studies have shown a correlation with increased operative time in total hip arthroplasty. Decreasing operative time and room time is essential to meeting the increased demand for total hip arthroplasty, and factors that influence these metrics should be quantified to allow for targeted reduction in time and adjusted reimbursement models. This is the first study to use a multivariate approach to identify which factors increase operative time and room time in total hip arthroplasty.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify a cohort of 30,361 patients having total hip arthroplasty between 2006 and 2012. Patient demographics, comorbidities including body mass index, and anesthesia type were used to create generalized linear models identifying independent predictors of increased operative time and room time.

RESULTS

Morbid obesity (body mass index >40) independently increased operative time by 13 minutes and room time 18 by minutes. Congestive heart failure led to the greatest increase in overall room time, resulting in a 20-minute increase. Anesthesia method further influenced room time, with general anesthesia resulting in an increased room time of 18 minutes compared with spinal or regional anesthesia.

CONCLUSION

Obesity is the major driver of increased operative time in total hip arthroplasty. Congestive heart failure, general anesthesia, and morbid obesity each lead to substantial increases in overall room time, with congestive heart failure leading to the greatest increase in overall room time.

Short-Term Complications of Distal Humerus Fractures in Elderly Patients: Open Reduction Internal Fixation Versus Total Elbow Arthroplasty

Background:

The purpose of this study was to evaluate 30-day postoperative complications of open reduction and internal fixation [ORIF] and total elbow arthroplasty [TEA] for the treatment of distal humerus fractures in elderly patients using a validated national database.

Methods:

Review of the National Surgical Quality Improvement Program (NSQIP) Database identified all elderly patients (>65 years) who underwent TEA or ORIF for the treatment of closed intra-articular distal humerus fractures from 2007 to 2013. Bivariate and multivariate analyses of risk factors for 30-day adverse events as defined by NSQIP between ORIF and TEA groups were assessed using preoperative and intraoperative variables.

Results:

Among the 176 patients with distal humerus fractures, there were 33 TEA and 143 ORIF. There was no difference in age, medical comorbidities, or functional status. Total elbow arthroplasty was associated with an increased odds of severe adverse event compared to ORIF (odds ratio = 1.57, P = .16), although it did not achieve statistical significance. Infection rate was 0.7% in ORIF and 0.0% in TEA (P = .99). Insulin-dependent diabetes and functional status were significant independent predictors of postoperative adverse events. Operative time (165 minutes vs 140 minutes, P = .06) and postoperative length of stay (3.6 days vs 2.3 days, P = 0.03) were longer for TEA compared to ORIF.

Conclusion:

Open reduction and internal fixation and TEA have similar 30-day postoperative complications for the treatment of distal humerus fractures among elderly patients. Despite favorable trends for TEA in recent studies, additional clinical results are needed to understand complications and limitation of TEA.

Level of evidence:

Level III, prognostic study.

The Effect of Diabetes Mellitus on Total Joint Arthroplasty Outcomes

Diabetes has negative effects on the outcomes of total joint arthroplasty, including increased numbers of complications, decreased function, early revision, and higher costs. The prevalence of diabetes is increasing rapidly worldwide; therefore, the orthopaedic surgeon should have an understanding of how diabetes affects surgical outcomes.

Factors Affecting Length of Stay and Complications After Elective Anterior Cervical Discectomy and Fusion: A Study of 2164 Patients From The American College of Surgeons National Surgical Quality Improvement Project Database (ACS NSQIP)

STUDY DESIGN

Retrospective review of the prospective American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database with 30-day follow-up of 2164 patients undergoing elective anterior cervical discectomy and fusion (ACDF).

OBJECTIVE

To determine factors independently associated with increased length of stay (LOS) and complications after ACDF to facilitate preoperative planning and setting of realistic expectations for patients and providers.

SUMMARY OF BACKGROUND DATA

The effect of individual preoperative factors on LOS and complications has been evaluated in small-scale studies. Large database analysis with multivariate analysis of these variables has not been reported.

METHODS

The ACS NSQIP database from 2005 to 2010 was queried for patients undergoing ACDF procedures. Preoperative and perioperative variables were collected. Multivariate regression determined significant predictors (P<0.05) of extended LOS and complications.

RESULTS

Average LOS was 2.0±4.0 days (mean±SD) with a range of 0-103 days. By multivariate analysis, age 65 years and above, functional status, transfer from facility, preoperative anemia, and diabetes were the preoperative factors predictive of extended LOS. Major complications, minor complications, and extended surgery time were the perioperative factors associated with increased LOS. The elongating effect of these variables was determined, and ranged from 0.5 to 5.0 days. Seventy-one patients (3.3%) had a total of 92 major complications, including return to operating room (40), venous thrombotic events (13), respiratory (21), cardiac (6), mortality (5), sepsis (4), and organ space infection (3). Multivariate analysis determined ASA score ≥3, preoperative anemia, age 65 years and above, extended surgery time, and male sex to be predictive of major complications (odds ratios ranging between 1.756 and 2.609). No association was found between levels fused and LOS or complications.

CONCLUSION

Extended LOS after ACDF is associated with factors including age, anemia, and diabetes, as well as the development of postoperative complications. One in 33 patients develops a major complication postoperatively, which are associated with an increased LOS of 5 days.

The Need for a Step-up in Postoperative Medical Care is Predictable in Orthopedic Patients Undergoing Elective Surgery

BACKGROUND

The goal of elective orthopedic surgery is to return patients to their expected level of activity without an increased incidence of postoperative complications. The first step is identifying patient and/or surgical characteristics responsible for these complications.

QUESTIONS/PURPOSES

This study sought to identify predictors of a step-up in medical care after non-ambulatory elective orthopedic surgery.

METHODS

At a single specialty orthopedic hospital, we identified all in-hospital postoperative patients who were transferred to a higher level of medical care ((PACU) post-anesthesia care unit). The characteristics of both transferred and non-transferred patients were compared. A model was built which incorporated predictors of return to a higher level of care.

RESULTS

During a 1-year period, 155 of 7967 patients (1.95%) required transfer to the PACU within 5 days of surgery. Cardiac complications were the major reason for transfer (50.3%), followed by pulmonary (11.0%) and neurological complications (9.7%). Patients who returned to the PACU were older, had more Exlihauser comorbidities, and had obstructive sleep apnea (OSA). In a model adjusting for all patient characteristics: age, American Society of Anesthesiologists (ASA) status, congestive heart failure (CHF), the Charlson comorbidity index and OSA predicted return to the PACU.

CONCLUSIONS

In an elderly population with multiple comorbidities undergoing elective common major orthopedic procedures, approximately 2% of patients required readmission to the PACU. The most common problems requiring this step-up in care were cardiac and pulmonary, which resulted in an increased length of hospital stay. Patients with OSA and multiple comorbidities undergoing total knee arthroplasty carry an increased risk for postoperative complications.