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

Is Preoperative Weight Reduction in Patients Who Have Body Mass Index ≥ 40 Associated with Lower Complication Rates After Primary Total Hip Arthroplasty?

INTRODUCTION

Given the heightened risk of postoperative complications associated with obesity, delaying total hip arthroplasty (THA) in patients who have a body mass index (BMI) > 40 to maximize pre-operative weight loss has been advocated by professional societies and orthopaedic surgeons. While the benefits of this strategy are not well understood, previous studies have suggested that a 5% reduction in weight or BMI may be associated with reduced complications after THA.

METHODS

We identified 613 patients who underwent primary THA in a single institution during a 7-year period, and who had a BMI > 40 recorded 9 to 12 months prior to surgery. Subjects were stratified into three cohorts based on whether their baseline BMI decreased by > 5% (147 patients, 24%), was unchanged (+/-5%) (336 patients, 55%), or increased by > 5% (130 patients, 21%) on the day of surgery. The frequency of 90-day Hip Society and Centers for Medicare & Medicaid Services (CMS) complications was compared between these cohorts. There were significant baseline differences between the cohorts with respect to baseline American Society of Anesthesiologists Class (P < 0.001) and hemoglobin A1C (P = 0.011), which were accounted for in a multivariate regression analysis.

RESULTS

In univariate analysis, there was a lower incidence of readmission (P = 0.025) and total complications (P = 0.005) in the increased BMI cohort. The overall complication rate was 18.4% in the decreased BMI cohort, 17.6% in the unchanged cohort, and 6.2% in the increased cohort. However, multivariable regression analysis controlling for potential confounders did not find that preoperative change in BMI was associated with differences in 90-day complications between cohorts (P > 0.05).

CONCLUSION

Patients who have a BMI > 40 and achieved a clinically significant (> 5%) BMI reduction prior to THA did not have a lower risk of 90-day complications or readmissions. Thus, delaying THA in these patients to encourage weight loss may result in restricting access to a beneficial surgery without an appreciable safety benefit.

Impact of body mass index on fracture severity, clinical, radiological and functional outcome in distal radius fractures: a retrospective observational study after surgical treatment

INTRODUCTION

Distal radius fracture (DRF) is one of the three most common fractures of the human body with increasing incidences in all groups of age. Known causes of increasing incidence, such as ageing of the population or increased obesity, have been described and discussed. So far, literature reports ambivalent effects of body mass index (BMI) on bone physiology. It is worthwhile to examine the influence of BMI on the outcome of fractures more detailed. This study aims to investigate the influence of an abnormal BMI on fracture severity and treatment, as well as clinical, radiological, and functional outcome to improve clinical decision making.

MATERIALS AND METHODS

A retrospective observational study was conducted on data obtained from patients, who underwent open reduction and internal fixation (ORIF) of a DRF at a local Level 1 Trauma Center between May 2018 and October 2021. Follow-up examinations were performed approximately 1 year after surgical fracture treatment, during which various questionnaires and functional measurements (CMS, DASH, NRS, ROM) were applied. In addition, postoperative complications were recorded and radiological examinations of the affected hand were performed. After excluding incomplete data sets and applying set exclusion criteria, the complete data of 105 patients were analyzed.

RESULTS

74 patients were female and 31 male with significant difference in mean BMI [p = 0.002; female: 23.8 (SD ± 3.3), men: 26.2 (SD ± 3.9)]. Patients with higher BMI had significantly more severe fractures (p = 0.042). However, there was no significant difference in surgery time for fracture management. At follow-up, patients with lower BMI showed a smaller difference in hand strength between the fractured and the other hand (p = 0.017). The BMI had no significant effect on the clinical and radiological outcome.

CONCLUSION

Despite the ambivalent effects of BMI on the skeletal system, our findings indicate that a higher BMI is associated with more severe DRF. Thereby BMI does not correlate with surgery time for fracture treatment. Furthermore, no evidence of an influence on the clinical and radiological outcome could be detected.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty

BACKGROUND

The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA).

METHODS

Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."

RESULTS

Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics.

CONCLUSIONS

The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

Study on the relationship between obesity and complications of Pediatric Epilepsy surgery

OBJECTIVE

Studies have shown that obesity has a significant impact on poor surgical outcomes. However, the relationship between obesity and pediatric epilepsy surgery has not been reported. This study aimed to explore the relationship between obesity and complications of pediatric epilepsy surgery and the effect of obesity on the outcome of pediatric epilepsy surgery, and to provide a reference for weight management of children with epilepsy.

METHODS

A single-center retrospective analysis of complications in children undergoing epilepsy surgery was conducted. Body mass index (BMI) percentiles were adjusted by age and used as a criterion for assessing obesity in children. According to the adjusted BMI value, the children were divided into the obese group (n = 16) and nonobese group (n = 20). The intraoperative blood loss, operation time, and postoperative fever were compared between the two groups.

RESULTS

A total of 36 children were included in the study, including 20 girls and 16 boys. The mean age of the children was 8.0 years old, ranging from 0.8 to 16.9 years old. The mean BMI was 18.1 ^kg/m2, ranging from 12.4 ^kg/m2 to 28.3 ^kg/m2. Sixteen of them were overweight or obese (44.4%). Obesity was associated with higher intraoperative blood loss in children with epilepsy (p = 0.04), and there was no correlation between obesity and operation time (p = 0.21). Obese children had a greater risk of postoperative fever (56.3%) than nonobese children (55.0%), but this was statistically nonsignificant (p = 0.61). The long-term follow-up outcomes showed that 23 patients (63.9%) were seizure-free (Engel grade I), 6 patients (16.7%) had Engel grade II, and 7 patients (19.4%) had Engel grade III. There was no difference in long-term seizure control outcomes between obese and nonobese groups (p = 0.682). There were no permanent neurological complications after surgery.

CONCLUSION

Compared with nonobese children with epilepsy, obese children with epilepsy had a higher intraoperative blood loss. It is necessary to conduct early weight management of children with epilepsy as long as possible.

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

Heart Failure is Associated with Early Medical and Surgery-Related Complications Following Total Hip Arthroplasty: A Propensity-Scored Analysis

INTRODUCTION

There is a paucity of literature that examines how heart failure (HF) impacts surgery-related complications following total hip arthroplasty (THA). We hypothesized that patients who had HF will be at increased risk of early medical- and surgery-related complications following THA.

METHODS

Patients who had HF and underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical complications, surgery-related complications, and hospital utilizations were evaluated for patients who did and did not have HF, as well as subgroup analyses were performed on patients who were prescribed mortality-benefitting medications for HF 1 year prior to THA. Propensity score matching resulted in 34,000 HF patients who underwent primary THA and 340,000 matching patients.

RESULTS

The HF cohort was associated with a higher 90-day incidence of pulmonary embolism (PE), deep vein thrombosis (DVT), transfusion, pneumonia, cerebrovascular accident (CVA), myocardial infarction (MI), sepsis, acute post hemorrhagic anemia, acute renal failure (ARF), and urinary tract infection (UTI), as well as 1-year risk of revision THA, periprosthetic joint infection (PJI), aseptic loosening, and dislocation compared to controls. The HF cohort was associated with a higher 90-day incidence of emergency department visits, readmissions, lengths of stay (LOS), and 1-year costs of care. The medication cohort was at decreased risk of PE, DVT, CVA, return to ED, readmission and MI within 90 days of surgery, and 1-year risk of revision THA and aseptic loosening.

DISCUSSION

These findings may help to better risk-stratify patients who have HF and are scheduled to undergo THA, as well as call for additional surveillance of these patients in the immediate and early postoperative period. This study also helps surgeons and internists understand how chronic medications used to treat HF can impact medical- and surgery-related outcomes following THA.

Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons?

BACKGROUND

As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon.

METHODS

A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents.

RESULTS

In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons.

CONCLUSION

A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.

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.

Obesity in Liver Transplantation: A Risk Factor for Unplanned Reoperation and Prolonged Operative Time

Selection of orthotopic liver transplantation (OLT) candidates is increasingly inclusive of patients with high BMI. We aim to characterize the influence of obesity on the surgical outcome measures of prolonged operative time and unplanned reoperation. We reviewed the records of obese and normal weight OLT recipients over a 10-year period from a single institution. Variables that trended ( P < 0.1) with endpoints on univariate analysis were put into multivariate logistic regression models to determine independent association ( P < 0.05). We included 195 obese and 171 normal weight OLT recipients in our study. On multivariate analysis, obesity was the only preoperative risk factor that trended with unplanned reoperation (odds ratio 2, P = 0.05). Similarly, only obesity remained independently associated with prolonged length of operation (defined as ≥275 minutes) on multivariate analysis (odds ratio 1.7, P = 0.04). In summary, obesity may make OLT more technically challenging and, thus, represents an independent risk factor for unplanned reoperations and prolonged operative time.

Continued Inpatient Care After Primary Total Shoulder Arthroplasty Is Associated With Increased Short-term Postdischarge Morbidity: A Propensity Score-Adjusted Analysis

Advances in surgical technique and implant design during the past several decades have resulted in annual increases in shoulder arthroplasty procedures performed in the United States. The purpose of this investigation was to use the National Surgical Quality Improvement Program database to analyze the rates of morbidity following shoulder arthroplasty. The authors hypothesized that, independent of predischarge patient factors, discharge to inpatient facilities is associated with increased short-term morbidity. Patient demographics, intraoperative variables, and information about postoperative complications/readmissions up to 30 days after the operative event were collected from the National Surgical Quality Improvement Program database for the period 2005 to 2015. Patients were divided into 2 cohorts based on discharge to home vs non-home facilities. Unadjusted baseline patient characteristics were compared using Pearson's chi-square test, and a propensity score-adjusted comparison was also performed. Overall, 9058 patients were included. Of these, 7996 (88.3%) were discharged to home and 1062 (11.7%) were discharged to a non-home facility. On propensity-adjusted analysis, complications determined to be statistically significantly associated with non-home discharge included cardiac (odds ratio, 4.19; 95% confidence interval, 1.75-10.04; P=.001), respiratory (odds ratio, 2.63; 95% confidence interval, 1.47-4.70; P=.001), urinary tract infection (odds ratio, 2.66; 95% confidence interval, 1.52-4.67; P=.001), and death (odds ratio, 7.51; 95% confidence interval, 2.42-23.27; P<.001). Overall, complications were statistically significantly associated with non-home discharges (odds ratio, 2.05; 95% confidence interval, 1.59-2.64; propensity-adjusted P<.001). This investigation indicated an association between postdischarge placement into non-home facilities and an increase in short-term morbidity, regardless of preoperative patient comorbidities. [Orthopedics. 2019; 42(2):e225-e231.].

How Fast Should a Total Knee Arthroplasty Be Performed? An Analysis of 140,199 Surgeries

BACKGROUND

Although previous studies have shown that prolonged operative times can lead to an increased risk of complications after total knee arthroplasty (TKA), they only evaluated a few complications. It is also unclear whether a distinctive operative time exists after which complications increase. Therefore, this study was performed to (1) assess whether higher operative time increases the risk of complications within 30 days of TKA and (2) explore the relationship between operative time and various complications to identify possible operative times where complication rates increase.

METHODS

The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 140,199 primary TKAs. The effect of operative time (skin-to-skin) on various medical and surgical complications within 30 days was evaluated using multivariable logistic regression models. Spline regression models were created to further study the relationship between operative time and complications.

RESULTS

After adjusting for confounding factors, longer operative times were associated with higher risks of readmission (P < .001), reoperation (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), and transfusion (P < .001). The majority of the complications demonstrated an increase throughout the range of operative time, with a slightly pronounced increase in the risk of complications when the operative time was longer than 80 minutes.

CONCLUSION

Prolonged operative times were associated with an increased risk of a number of important complications such as readmissions, reoperations, surgical site infections, and wound complications. Based on our results, an operative time goal of less than 80 minutes is helpful for minimizing these complications after TKA.

Impact of Body Mass Index on Perioperative Outcomes of Endoscopic Pituitary Surgery

Background Endoscopic pituitary surgery (EPS) is increasingly being used for the treatment of pituitary lesions. Obesity is a growing epidemic in our nation associated with numerous comorbidities known to impact surgical outcomes. We present a multi-institutional database study evaluating the association between body mass index (BMI) and postsurgical outcomes of EPS. Methods Patients who underwent EPS from 2005 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Preoperative variables, comorbidities, and postoperative outcomes, such as 30-day complications, morbidity, and mortality, were analyzed. Results A total of 789 patients were analyzed, of which 382 were obese (BMI ≥ 30) (48.4%). No difference in reoperation rate ( P = .928) or unplanned readmission rates ( P = .837) was found between the obese versus nonobese group. A higher overall complication rate was observed in the obese group compared to the nonobese counterparts ( P = .005). However, when separated into surgical complications (3.7% vs 1.5%, P = .068) and medical complications (7.6% vs 3.9%, P = .027), only medical complications, specifically pneumonia, remained significantly different. EPS on obese patients was also associated with prolonged operating time (154.8 min vs 141.0 min, P = .011). Conclusions EPS may be a safe treatment option for pituitary lesions in the obese population. Although obese patients undergoing EPS are at increased risk of medical complications and prolonged operating times, this did not influence mortality, reoperation, or readmission rate.

Computer Navigated Total Knee Arthroplasty: Rates of Adoption and Early Complications

BACKGROUND

When new technologies are introduced, it is important to evaluate the rate of adoption and outcomes compared with preexisting technology. The purpose of this study was to determine the adoption rate of computer-assisted navigation in total knee arthroplasty (TKA), to determine if the short-term complication rate changed over time with navigation, and to compare short-term complication rates of navigated and traditional TKA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 108,277 patients undergoing primary TKA between 2010 and 2014, of which 3573 cases (3.30%) were navigated. Rates of adoption of navigated TKA were determined. Differences in short-term complications by year were compared using propensity score matching.

RESULTS

Navigation utilization decreased from 4.96% in 2010 to 3.06% in 2014. Blood transfusion rates for the entire cohort decreased from 19% in 2011 to 6% in 2014, and was not decreased with navigation compared with traditional TKA in 2014 (P = .1309). Operative time was not increased by navigation, and average 94.2 minutes. There were no significant differences in all-cause complications, reoperation rate, unplanned readmission, or length of stay for any year.

CONCLUSIONS

There was a 38.3% decrease in TKA navigation utilization from 2010-2014. Blood transfusion rates decreased 68% over the 5-year study, and were not decreased with navigation in 2014. Navigation was not found to increase operative time. There were no significant differences in short-term complications, readmission rate, or length of stay between navigated and traditional TKA.

Can We Predict Discharge Status After Total Joint Arthroplasty? A Calculator to Predict Home Discharge

BACKGROUND

Postoperative discharge to a skilled nursing facility after total joint arthroplasty (TJA) is associated with increased costs, complications, and readmission. The purpose of this study was to identify the risk factors for discharge to a location other than home to build a calculator to predict discharge disposition after TJA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2013 to identify patients who underwent primary total hip or total knee arthroplasty. Risk factors were compared between patients discharging home vs a facility. Predictors of facility discharge were converted to discrete values to develop a simple numerical calculator.

RESULTS

After primary TJA, patients discharged to a facility were typically older (70.9 vs 64.3, P < .001), female (69.5% vs 55.7%, P < .001), had an elevated American Society of Anesthesiologist (ASA) class, and were more likely to be functionally dependent before surgery (3.8% vs 1.1%, P < .001). Patient age, preoperative functional status, nonelective THA for hip fracture, and ASA class were most predictive of facility discharge. After development of a predictive model, scores exceeding 40 and 80 points resulted in a facility discharge probability of 75% and 99%, respectively.

CONCLUSION

In patients undergoing TJA, advanced age, elevated ASA class, and functionally dependent status before surgery strongly predicted facility discharge. Given that facility discharge imposes a significant cost and morbidity burden after TJA, patients, surgeons, and hospitals may use this simple calculator to target this susceptible patient population.

Use of Historical Surgical Times to Predict Duration of Primary Total Knee Arthroplasty

BACKGROUND

Primary total knee arthroplasty (TKA) is one of the most commonly performed procedures at US hospitals. Surgeons are typically asked to estimate surgical control time (SCT) needed for the procedure. Here, we compare the performance of a surgeon's prediction against a potentially more accurate method of using historical averages over the last 3, 5, 10, and 20 cases.

METHODS

Data were collected on all scheduled primary TKAs done at one institution from October 2008 to September 2014. For each case, actual SCT (aSCT) and predicted SCT were obtained. Historical SCTs were calculated based on the mean of the last 3, 5, 10, and 20 aSCTs of the same surgeon. Estimation biases were calculated based on the difference between aSCT and predicted SCT or between aSCT and historical estimates. Values were compared using Kruskal-Wallis analysis of variance and Steel-Dwass pairwise comparisons.

RESULTS

A total of 2539 primary TKAs were evaluated across 9 surgeons. Surgeons overestimated SCT by an average of 18.1 minutes. Using 3-20 cases in the historical average reduced mean estimation bias to a range of -0.1 to -0.3 minutes (P < .001). None of the historical estimations were significantly different from each other, demonstrating a lack of improvement with additional cases (P < .001).

CONCLUSION

Historical averages of procedure times appear to be a promising method of estimating surgical time for primary TKAs. Here, we show that even a small number of cases (eg, 3) can reduce estimation biases compared to solely using surgeons' estimates alone.