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Esteves TA, Buljubasich M, Holc F, Costantini J, Nicolino TI, Carbo L. Complications in simultaneous bilateral total knee arthroplasty, is it a safe procedure? J ISAKOS 2023; 8:451-455. [PMID: 37619961 DOI: 10.1016/j.jisako.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 07/25/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND There is controversy regarding various aspects of simultaneous bilateral total knee replacement (SBTKR). We found disparity in the postoperative outcomes and complications associated with the procedure in the literature linked with the topic. OBJECTIVE To retrospectively analyze the need for blood transfusion after surgery and complications associated with total knee replacement according to the type of procedure (SBTKR or unilateral). METHODS Retrospective cohort analytical study. We included 251 patients with severe knee osteoarthritis that were divided into two groups. 124 (49%) who underwent SBTKR and 127 upon whom unilateral total knee replacement (UTKR) was performed. Demographic data, days of hospitalization, complications within the first 90 days after surgery (thromboembolic events, superficial and deep infection, stiffness, death); and percentages of patients transfused with blood products during hospitalization were evaluated. RESULTS There were no statistical differences in the analysis of postoperative complications in the first 90 days after surgery. In the SBTKR group, 8 patients (6.5%) presented some thromboembolic complication during the postoperative period, while this event was observed in only 2 patients (1.5%) from the other group. The analysis showed a statistically significant drop in postoperative hemoglobin, on average that of 0.8 g/dl, in the SBTKR patient group compared to the UTKR group (95% CI 0.44-1.13; p < 0.001). A higher proportion of patients who required transfusion were observed in the SBTKR group (40%) (OR = 7.12; 95% CI 3.3-16; p < 0.001). We analyzed the cause of postoperative transfusion in the patients who required transfusion taking into account two parameters: hemoglobin less than 8 g/dl and the clinical needs of the patients (symptoms of hypotension, decay, difficulty to rehabilitate without pain, dyspnea). 59 patients received transfusion (50 in the SBTKR group and 9 in the other group). Of these, 19 patients (32.2%) did not meet any transfusion criteria. CONCLUSION We consider SBTKR a safe procedure, which does not increase postoperative complications compared to UTKR. Although there is an increase in blood loss in SBTKR, it does not generate clinical symptoms of relevance. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tomás Alfredo Esteves
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina.
| | - Martín Buljubasich
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina
| | - Fernando Holc
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina
| | - Julián Costantini
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina
| | - Tomás Ignacio Nicolino
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina
| | - Lisandro Carbo
- Department of Orthopedics and Traumatology, Sector of Knee Arthroscopy and Reconstruction Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, CABA, CP: 1199, Buenos Aires, Argentina
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A Time-Driven Activity-Based Costing Analysis of Simultaneous Versus Staged Bilateral Total Hip Arthroplasty and Total Knee Arthroplasty. J Arthroplasty 2022; 37:S742-S747. [PMID: 35093545 DOI: 10.1016/j.arth.2022.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA. METHODS We reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous). RESULTS Simultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P < .001) and $704 lower in TKA (P < .001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P < .001). CONCLUSION Simultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.
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Crespi Z, Hasan AI, Pearl A, Ismail A, Awad ME, Irfan FB, Jaffar M, Patel P, Saleh KJ. Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries. JBJS Rev 2022; 10:01874474-202203000-00012. [PMID: 35290253 DOI: 10.2106/jbjs.rvw.21.00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC. » Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively. » The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team. » Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.
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Affiliation(s)
- Zachary Crespi
- College of Medicine, Central Michigan University, Mount Pleasant, Michigan
| | - Ahmad I Hasan
- School of Medicine, Wayne State University, Detroit, Michigan.,FAJR Scientific, Northville, Michigan
| | - Adam Pearl
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Aya Ismail
- FAJR Scientific, Northville, Michigan.,University of Michigan, Dearborn, Michigan
| | - Mohamed E Awad
- FAJR Scientific, Northville, Michigan.,NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Michigan State University-College of Osteopathic Medicine, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Furqan B Irfan
- Michigan State University-College of Osteopathic Medicine, Detroit, Michigan
| | - Muhammed Jaffar
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Padmavathi Patel
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- FAJR Scientific, Northville, Michigan.,Michigan State University-College of Osteopathic Medicine, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
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Abdelaal MS, Calem D, Sherman MB, Sharkey PF. Short Interval Staged Bilateral Total Knee Arthroplasty: Safety Compared to Simultaneous and Later Staged Bilateral Total Knee Arthroplasty. J Arthroplasty 2021; 36:3901-3908. [PMID: 34580003 DOI: 10.1016/j.arth.2021.08.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/18/2021] [Accepted: 08/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Simultaneous bilateral total knee arthroplasty (sim-BTKA) is reported to be safe in a select group of patients. Patients with symptomatic bilateral knee arthritis who are not candidates for sim-BTKA require staged surgery (stag-BTKA). This study aimed to compare the safety and complications associated with sim-BTKA with stag-BTKA performed at 2 time intervals. METHODS This retrospective study of prospectively collected data includes bilateral TKA cases performed between 2001 and 2019. A cohort of sim-BTKA (n = 2728) was compared to a cohort of stag-BTKA (n = 1658). The staged group was subdivided according to the interval between surgeries: ≤90 days (early) and ≥91 days (later). Multivariate logistic regression analyses were used to adjust for confounding variables. RESULTS In-hospital complication rates were lower in both arms of the stag-BTKA groups vs the sim-BTKA. The sim-BTKA group had higher odds ratio of anemia, electrolyte disturbances, pulmonary embolism, and respiratory, urinary, gastrointestinal, and neurological complications. Lower rates of all-cause revision were found in stag-BTKA vs sim-BTKA groups. There was a trend toward revision due to deep infection when increasing the interim before the second stag-BTKA procedure. No differences in complication rates after the second surgery were detected between the early and later stag-BTKA. CONCLUSION This study demonstrates that sim-BTKA is associated with more complications and revisions when compared to stag-BTKA. Performing the second-stage TKA at 90 days or less after the first TKA is not associated with increased risk of complications. Performing sim-BTKA, simply for convenience, is not warranted and should be reserved for a select group of patient matching specific criteria.
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Affiliation(s)
- Mohammad S Abdelaal
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Daniel Calem
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew B Sherman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Peter F Sharkey
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Chan SK, Opanova MI, Thorne TJ, Matsumoto MY, Andrews SN, Nakasone CK. Can obese patients undergo simultaneous bilateral total knee arthroplasty without an increased risk of perioperative complications? J Orthop 2021; 27:137-140. [PMID: 34629787 DOI: 10.1016/j.jor.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/26/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022] Open
Abstract
Simultaneous bilateral total knee arthroplasty (simBTKA) remains controversial, especially in obese patients. Therefore, this retrospective study compared six month perioperative complications in 313 simBTKA patients. Comparison groups included 139 non-obese patients (BMI < 30), 61 obese patients (BMI = 30-35) and 48 severely obese patients (BMI > 35). Increased BMI was associated with longer tourniquet and surgical times (p < 0.001). However, no differences were found for transfusion (p = 0.288), deep infection (p = 0.971), pulmonary embolism (p = 0.454), or deep vein thrombosis (p = 0.670). Increased BMI was, therefore, not associated with greater post-operative complications and should not necessarily contraindicate simBTKA.
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Affiliation(s)
- Sean K Chan
- University of Hawai'i, John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Mariya I Opanova
- University of Hawai'i, John A. Burns School of Medicine, Department of Surgery, 1356 Lusitana Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone & Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
| | - Tyler J Thorne
- University of Hawai'i, John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Maya Y Matsumoto
- University of Hawai'i, John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone & Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
| | - Samantha N Andrews
- University of Hawai'i, John A. Burns School of Medicine, Department of Surgery, 1356 Lusitana Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone & Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
| | - Cass K Nakasone
- University of Hawai'i, John A. Burns School of Medicine, Department of Surgery, 1356 Lusitana Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone & Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
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7
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Acuña AJ, Grits D, Samuel LT, Emara AK, Kamath AF. Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs. Clin Orthop Relat Res 2021; 479:589-600. [PMID: 33165044 PMCID: PMC7899570 DOI: 10.1097/corr.0000000000001513] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power. QUESTIONS/PURPOSES Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as "non-elective" were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients' transfusion status. Significance was determined at a p value < 0.05. RESULTS Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching. CONCLUSION After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Alexander J Acuña
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Daniel Grits
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Linsen T Samuel
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Ahmed K Emara
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Atul F Kamath
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Jenny JY, Bulaid Y, Boisrenoult P, Bonin N, Henky P, Tracol P, Chouteau J, Courtin C, Henry MP, Schwartz C, Mertl P, De Ladoucette A. Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program. Orthop Traumatol Surg Res 2020; 106:1533-1538. [PMID: 33127330 DOI: 10.1016/j.otsr.2020.02.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HYPOTHESIS The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. METHODS This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. RESULTS Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DISCUSSION The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed. LEVEL OF EVIDENCE IV; Prospective cohort study without control group.
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Affiliation(s)
- Jean-Yves Jenny
- Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - Yassine Bulaid
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
| | - Philippe Boisrenoult
- Center Hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Nicolas Bonin
- Lyon Ortho Clinic, 29B, avenue des Sources, 69009 Lyon, France
| | - Pierre Henky
- Clinique Rhéna, 10, rue François Epailly, 67000 Strasbourg, France
| | - Philippe Tracol
- Cité Santé Plus, 1021, avenue Pierre Mendès France, 84300 Cavaillon, France
| | - Julien Chouteau
- Clinique d'Argonay, 685, route des Menthonnex, 74370 Argonay, France
| | - Cyril Courtin
- Hospices Civils de Lyon-Hôpital Lyon Sud, 165, chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Marc-Pierre Henry
- Centre Hospitalier Régional Universitaire de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - Claude Schwartz
- Polyclinique des Trois Frontières, 8, rue Saint-Damien, 68300 Saint-Louis, France
| | - Patrice Mertl
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
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Santana DC, Emara AK, Orr MN, Klika AK, Higuera CA, Krebs VE, Molloy RM, Piuzzi NS. An Update on Venous Thromboembolism Rates and Prophylaxis in Hip and Knee Arthroplasty in 2020. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E416. [PMID: 32824931 PMCID: PMC7558636 DOI: 10.3390/medicina56090416] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022]
Abstract
Patients undergoing total hip and knee arthroplasty are at high risk for venous thromboembolism (VTE) with an incidence of approximately 0.6-1.5%. Given the high volume of these operations, with approximately one million performed annually in the U.S., the rate of VTE represents a large absolute number of patients. The rate of VTE after total hip arthroplasty has been stable over the past decade, although there has been a slight reduction in the rate of deep venous thrombosis (DVT), but not pulmonary embolism (PE), after total knee arthroplasty. Over this time, there has been significant research into the optimal choice of pharmacologic VTE prophylaxis for individual patients, with the objective to reduce the rate of VTE while minimizing adverse side effects such as bleeding. Recently, aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents. However, there is no evidence to date that clearly demonstrates the superiority of any given prophylactic agent. Therefore, this review discusses (1) the current prevalence and trends in VTE after total hip and knee arthroplasty and (2) provides an update on pharmacologic VTE prophylaxis in regard to aspirin usage.
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Affiliation(s)
- Daniel C. Santana
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Melissa N. Orr
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Carlos A. Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA;
| | - Viktor E. Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
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10
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Safety and efficacy of sequential simultaneous bilateral total knee arthroplasty: A single centre retrospective cohort study. J Clin Orthop Trauma 2020; 11:S636-S644. [PMID: 32774041 PMCID: PMC7394781 DOI: 10.1016/j.jcot.2020.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Simultaneous bilateral total knee arthroplasty (TKA) is a promising option for patients with bilateral arthritis of the knee because of the requirement of a single hospitalization and anesthetic regimen, reduced overall hospital stay, lower overall costs, and quicker recovery compared to staged bilateral TKA. However, there are conflicting reports on the safety of the procedure, with little data available in the Indian setting. Herein, we compared the efficacy and safety of sequential simultaneous bilateral TKA (SSBTKA) with those of unilateral TKA (UTKA). METHODS This retrospective analysis included cases of SSBTKA (n = 380, 760 knees) and UTKA (n = 754) performed by the same surgeon and followed up for a minimum duration of 1 year. The functional outcomes (postoperative changes in Oxford Knee Score [OKS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), length of hospital stay (LOS), complications, and rates of revision and mortality were compared between the two groups. RESULTS The mean follow-up durations were 40.59 and 36.69 months for the UTKA and SSBTKA groups, respectively. The LOS was significantly longer in the SSBTKA group than in the UTKA group (Median [Interquartile range]: 4[1] vs. 3[0], p < 0.001). The OKS and WOMAC scores increased with time in both groups. The improvements in each of these scores at 3, 6, and 12 months postoperatively were either statistically similar between the two groups or, if statistically different, the differences were too small to be clinically meaningful. Blood transfusions (4% [SSBTKA] vs.0.3% [UTKA], p < 0.001), cardiac complications (1.6% vs. 0.4%, p = 0.034), urine retention (3.7% vs. 1.2%, p = 0.005), and deep infection (0.8% vs. 0%, p = 0.015) were significantly more frequent in the SSBTKA group. None of the patients in the UTKA group had to undergo revision surgery, whereas in the SSBTKA group, 2 (0.6%) patients underwent revision TKA. The overall mortality rates were low in both groups (0.8% [SSBTKA] and 0.3% [UTKA]), with no significant between-group difference (p = 0.209). CONCLUSION The functional outcomes and mortality rates associated with SSBTKA are comparable to those associated with UTKA. The risk of complications and the need for revision, although higher with SSBTKA, the actual numbers are low enough to justify its use. Although the LOS in SSBTKA is longer than that in UTKA, it is likely to be shorter than the cumulative LOS for two UTKA procedures (i.e. a staged bilateral TKA). Thus, SSBTKA appears to be a safe and effective choice for appropriately selected patients.
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Cao G, Chen G, Yang X, Huang Q, Huang Z, Xu H, Alexander PG, Zhou Z, Pei F. Obesity does not increase blood loss or incidence of immediate postoperative complications during simultaneous total knee arthroplasty: A multicenter study. Knee 2020; 27:963-969. [PMID: 32057638 DOI: 10.1016/j.knee.2020.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 01/17/2020] [Accepted: 01/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of the study was to determine blood loss, transfusion risk, and incidence of immediate postoperative complications in normal, overweight, and I-II obese patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). METHOD We identified 1070 SBTKA procedures, and separated the patients into three groups on the basis of body mass index (BMI), including normal (BMI: 18.0-24.9 kg/m2), overweight (BMI: 25.0-29.9 kg/m2), and obese groups (BMI: ≥30.0 kg/m2). The primary outcome was total blood loss and secondary outcomes were dominant and hidden blood loss, transfusion rate and volume, hemoglobin (Hb) and hematocrit drop and other complications. RESULTS Patient's blood volume increased gradually among normal, overweight, and obese groups. There was no significant difference in blood loss or incidence of complications among the three groups, while the transfusion rate in the normal group was higher than that in overweight (36.0% vs 27.6%, p = 0.007) and obese groups (36.0% vs 24.6%, p = 0.006). In addition, the independent risk factors for complications among all groups following SBTKA included lower level of preoperative Hb (p = 0.040), general anesthesia (p = 0.002), drain use (p = 0.005), and transfusion (p < 0.001). CONCLUSIONS I-II obesity does not increase patient's blood loss, transfusion risk, or immediate postoperative complications following SBTKA. Obese and overweight patients may have lower transfusion needs compared with normal patients because of their higher basal blood volume. The risk factors for complications after SBTKA are lower level of preoperative Hb, general anesthesia, drain use and transfusion.
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Affiliation(s)
- Guorui Cao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Guo Chen
- Department of Geriatric Orthopedic (1), Sichuan Provincial Orthopedic Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Xiuli Yang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Peter G Alexander
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, USA
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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Warren JA, Sundaram K, Anis HK, Kamath AF, Higuera CA, Piuzzi NS. Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty? J Arthroplasty 2020; 35:259-264. [PMID: 31530463 DOI: 10.1016/j.arth.2019.08.049] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/13/2019] [Accepted: 08/22/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA). METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference. RESULTS Overall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05). CONCLUSION Approximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Hiba K Anis
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Warren JA, Sundaram K, Kamath AF, Molloy RM, Krebs VE, Mont MA, Piuzzi NS. Venous Thromboembolism Rates Did Not Decrease in Lower Extremity Revision Total Joint Arthroplasty From 2008 to 2016. J Arthroplasty 2019; 34:2774-2779. [PMID: 31153709 DOI: 10.1016/j.arth.2019.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis [DVT] and/or pulmonary embolism [PE] in the same patient), DVT, PE, and mortality in the 30-day period after rTKA and rTHA. METHODS We identified 30,406 rTKA and rTHA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest. RESULTS The overall incidences of 30-day VTE, DVT, PE, and mortality for rTKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in rTHA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period. CONCLUSION Within 30 days of surgery, approximately 1 in 83 rTKA patients and 1 in 100 rTHA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in rTKA and rTHA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in rTHA and rTKA.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Viktor E Krebs
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Rondon AJ, Phillips JLH, Fillingham YA, Gorica Z, Austin MS, Courtney PM. Bundled Payments Are Effective in Reducing Costs Following Bilateral Total Joint Arthroplasty. J Arthroplasty 2019; 34:1317-1321.e2. [PMID: 30992236 DOI: 10.1016/j.arth.2019.03.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/25/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Alternative payment models such the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative have been effective in reducing costs following unilateral total hip (THA) and knee arthroplasty (TKA), but few studies exist on bilateral arthroplasty. This study aimed to determine whether the BPCI program for bilateral THA and TKA reduced episode-of-care costs. METHODS We retrospectively reviewed a consecutive series of patients who underwent simultaneous bilateral primary THA and TKA between 2015 and 2016. We recorded demographic variables, comorbidities, readmissions, and calculated 90-day episode-of-care costs based on Centers for Medicare and Medicaid Services claims data. We compared data from patients before and after the start of our BPCI program, and performed a multivariate analysis to identify independent risk factors for increased costs. RESULTS Of 319 patients, 38 underwent bilateral THA (12%) while 287 underwent bilateral TKA (88%). There were 239 patients (74%) in the bundled payment group. Although there was no change in readmission rate (9% vs 8%), the post-BPCI group demonstrated reduced hospital costs ($21,251 vs $18,783), post-acute care costs ($15,488 vs $12,439), and overall 90-day episode-of-care costs ($39,733 vs $34,305). When controlling for demographics, procedure, and comorbidities, our BPCI model demonstrated a per-patient reduction of $5811 in overall claims costs. Additional risk factors for increased episode-of-care costs included age ($516/y increase) and cardiac disease ($5916). CONCLUSION Our bundled payment program for bilateral THA and TKA was successful with reduction in 90-day episode-of-care costs without placing the patient at higher risk of readmission. Older Medicare beneficiaries and those with cardiac disease should likely not undergo a simultaneous bilateral procedure due to concerns about increased costs.
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Affiliation(s)
| | | | - Yale A Fillingham
- Department of Orthopaedics, Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Zylyftar Gorica
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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