Impact of Postoperative Zolpidem Use on Primary Total Knee Arthroplasty: A Retrospective Matched-Controlled Analysis of a Private Insurance Database

Sleep Disturbance Trends in the Short-Term Postoperative Period for Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep.

METHODS

This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep.

RESULTS

The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks ( P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks ( P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively.

DISCUSSION

Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep.

STUDY DESIGN

Retrospective analysis of prospectively collected data.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

A Case-Control Study of Accidental Falls During Surgical Hospitalizations

BACKGROUND

Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications.

METHODS

Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed.

RESULTS

There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 - 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001).

CONCLUSIONS

The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.

Melatonin Does Not Improve Sleep Quality in a Randomized Placebo-controlled Trial After Primary Total Joint Arthroplasty

INTRODUCTION

Sleep disturbance is a common concern among patients who have undergone total joint arthroplasty (TJA). Poor sleep during the postoperative period affect quality of life directly and may influence pain recovery after TJA. The purpose of this prospective study was to investigate whether the daily use of exogenous melatonin for 6 weeks after TJA can mitigate the effects of TJA on sleep.

METHODS

A cohort of 118 patients undergoing primary total hip arthroplasty or total knee arthroplasty from 2018 to 2020 were randomized to melatonin (6 mg) or placebo for 42 days after surgery. Inclusion criterion was patients undergoing unilateral primary TJA. Patients who underwent bilateral TJA and revision TJA, with a history of sleep disturbance, and on opioid medication or sleep aids preoperatively were excluded. Sleep quality was assessed at baseline and at 2 and 6 weeks postoperatively using the validated self-administered questionnaire, Pittsburgh Sleep Quality Index (PSQI). Continuous and categorical variables were analyzed using Student t-test and chi-square analysis, respectively. Multivariate linear regression analysis was also conducted.

RESULTS

Patients in both groups exhibited higher PSQI scores, representing lower sleep quality, at both 2 and 6 weeks postoperatively compared with that at baseline. Overall, global PSQI scores were 6.8, 9.8, and 8.8 at baseline, week 2, and week 6, respectively. No significant differences were noted between melatonin and placebo groups at baseline (6.8 versus 6.8, P = 0.988), week 2 (10.2 versus 9.3, P = 0.309), or week 6 (8.8 versus 8.7, P = 0.928). In multivariable regression, the only significant predictors of increased PSQI scores were an elevated baseline PSQI score (at both time points), a decreased length of stay (at week 2 only), and patients undergoing total hip arthroplasty versus total knee arthroplasty (at week 6 only).

CONCLUSION

Patients undergoing TJA had poor sleep quality both preoperatively and postoperatively. The use of exogenous melatonin did not demonstrate any notable effect on sleep quality.