1
|
Zhang N, Zhang D, Ren S, Gao Y, Sun W, Yang S. Relationship between preoperative hemoglobin levels and length of stay in elderly patients with hip fractures: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e38518. [PMID: 38905374 PMCID: PMC11191984 DOI: 10.1097/md.0000000000038518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/17/2024] [Indexed: 06/23/2024] Open
Abstract
Globally, hip fractures in elderly individuals are a prevalent and serious issue. Patients typically have a longer length of stay (LOS), which increases the risk of complications and increases hospitalization costs. Hemoglobin (Hb) is a routine blood test that is associated with disease prognosis. This study aimed to investigate the relationship between preoperative Hb and LOS in elderly hip fracture patients and to determine a reliable transfusion threshold. The clinical data of hip fracture patients (aged ≥ 60 years) admitted to the Department of Orthopaedics, Shenzhen Second People's Hospital, between January 2012 and December 2021 were retrospectively analyzed. Multiple linear regression analysis was used to assess the linear relationship between preoperative Hb and LOS. Smooth curve fitting was performed to investigate potential nonlinear relationships. In the case of discovering nonlinear relationships, a weighted two-piecewise linear regression model was built, and the inflection points were determined using a recursive algorithm. Subgroup analyses were conducted based on age and gender. A total of 1444 patients with an average age of (77.54 ± 8.73) years were enrolled. After adjusting for covariates, a nonlinear relationship was found between preoperative Hb and LOS. The two-piecewise linear regression model revealed an inflection point of 10 g/dL. On the left of the inflection point (Hb < 10 g/dL), the LOS was reduced by 0.735 days for every 1 g/dL increase in Hb (β = -0.735, 95% confidence interval: -1.346 to -0.124, P = .019). On the right side of the inflection point (Hb > 10 g/dL), the relationship was not statistically significant (β = 0.001, 95% confidence interval: -0.293 to 0.296, P = .992). In elderly hip fracture patients, there is a nonlinear association between preoperative Hb and LOS. However, when Hb levels were <10 g/dL, there was a negative correlation with the LOS. No correlation was observed when Hb levels were >10 g/dL. These findings underscore the importance of timely intervention to manage Hb levels in elderly patients with hip fractures, potentially reducing hospitalization durations and associated complications.
Collapse
Affiliation(s)
- Ning Zhang
- School of Nursing, Anhui Medical University, Hefei, China
| | - Daxue Zhang
- School of Nursing, Anhui Medical University, Hefei, China
| | - Shuqun Ren
- Guangxi University of Chinese Medicine, Nanning, China
| | - Yan Gao
- Department of Rehabilitation Medicine, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Weichao Sun
- Department of Bone and Joint Surgery, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Shiwei Yang
- School of Nursing, Anhui Medical University, Hefei, China
- Teaching Office, Shenzhen Second People’s Hospital, Shenzhen, China
| |
Collapse
|
2
|
Ardon AE. Safety Considerations for Outpatient Arthroplasty. Anesthesiol Clin 2024; 42:281-289. [PMID: 38705676 DOI: 10.1016/j.anclin.2023.11.009] [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] [Indexed: 05/07/2024]
Abstract
Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.
Collapse
Affiliation(s)
- Alberto E Ardon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| |
Collapse
|
3
|
Harris AB, Root KT, Cueto R, Diaz MJ, Zhao A, Oni JK, Hegde V, Khanuja HS. The Definition of Anemia Matters When Using Preoperative Hemoglobin as a Screening Tool Prior to Total Hip and Knee Arthroplasty. J Arthroplasty 2024; 39:1240-1244. [PMID: 37939888 DOI: 10.1016/j.arth.2023.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Preoperative anemia is common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Several definitions of anemia have been described, with no clear consensus on the optimal one for preoperative screening. We hypothesized that depending on the definition used preoperatively, the proportion of anemic patients identified who would require a postoperative allogeneic blood transfusion would vary significantly. METHODS A total of 681,141 patients were identified in a national database who underwent either THA or TKA. Preoperative anemia was classified according to the World Health Organization (WHO) definition, Cleveland Clinic (CC) definition, or race, age, and sex-specific definition described by Beutler et al in 2006. The optimal preoperative (OP) hemoglobin thresholds to predict perioperative transfusions were also calculated using receiver operating characteristic curves. RESULTS When using the WHO definition, 18% of anemic patients required a transfusion versus 14% (OP definition), 12% (CC definition), and 16% (Beutler definition). Similarly, 0.69% of anemic patients sustained a periprosthetic joint infection within 30 days using the WHO definition versus 0.59% (OP definition), 0.60% (CC definition), or 0.66% (Beutler definition). Using the WHO definition, 5.3% of patients would have sustained a major complication versus 4.5% (OP definition), 4.4% (CC definition), and 5.0% (Beutler definition). CONCLUSIONS Variation in the definition of anemia for preoperative screening in THA and TKA results in substantial differences in discriminative ability to predict perioperative transfusions. The WHO definition identified the largest proportion of patients who ultimately received a perioperative transfusion.
Collapse
Affiliation(s)
- Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Kevin T Root
- University of Florida College of Medicine, Gainesville, Florida
| | - Robert Cueto
- University of Florida College of Medicine, Gainesville, Florida
| | - Michael J Diaz
- University of Florida College of Medicine, Gainesville, Florida
| | - Amy Zhao
- The George Washington University College of Medicine, Washington, District of Columbia
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
4
|
Schmidt-Braekling T, Sabri E, Kim PR, Gofton WT, Beaulé PE, Grammatopoulos G. Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases? Arch Orthop Trauma Surg 2024; 144:2337-2346. [PMID: 38416136 DOI: 10.1007/s00402-024-05247-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Tom Schmidt-Braekling
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul R Kim
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Wade T Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada.
| |
Collapse
|
5
|
Zhang FQ, Yang YZ, Li PF, Ma GR, Zhang AR, Zhang H, Guo HZ. Impact of preoperative anemia on patients undergoing total joint replacement of lower extremity: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:249. [PMID: 38637795 PMCID: PMC11027536 DOI: 10.1186/s13018-024-04706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
PURPOSE Preoperative anemia increases postoperative morbidity, mortality, and the risk of allogeneic transfusion. However, the incidence of preoperative anemia in patients undergoing total hip arthroplasty and total knee arthroplasty (TKA) and its relationship to postoperative outcomes has not been previously reported. METHODS We conducted a comprehensive literature search through PubMed, Cochrane Library, Web of Sincien, and Embase from inception to July 2023 to investigate the prevalence of preoperative anemia in patients undergoing Total Joint Arthroplasty, comorbidities between anemic and non-anemicpatients before surgery, and postoperative outcomes. postoperative outcomes were analyzed. Overall prevalence was calculated using a random-effects model, and heterogeneity between studies was examined by Cochran's Q test and quantified by the I2 statistic. Subgroup analyses and meta-regression analyses were performed to identify sources of heterogeneity. Publication bias was assessed by funnel plots and validated by Egger's test. RESULTS A total of 21 studies with 369,101 samples were included, all of which were retrospective cohort studies. 3 studies were of high quality and 18 studies were of moderate quality. The results showed that the prevalence of preoperative anemia was 22% in patients awaiting arthroplasty; subgroup analyses revealed that the prevalence of preoperative anemia was highest in patients awaiting revision of total knee arthroplasty; the highest prevalence of preoperative anemia was found in the Americas; preoperative anemia was more prevalent in the female than in the male population; and preoperative anemia with a history of preoperative anemia was more common in the female than in the male population. patients with a history of preoperative anemia; patients with joint replacement who had a history of preoperative anemia had an increased risk of infection, postoperative blood transfusion rate, postoperative blood transfusion, Deep vein thrombosis of the lower limbs, days in hospital, readmission within three months, and mortality compared with patients who did not have preoperative anemia. CONCLUSION The prevalence of preoperative anemia in patients awaiting total joint arthroplasty is 22%, and is higher in TKA and female patients undergoing revision, while preoperative anemia is detrimental to the patient's postoperative recovery and will increase the risk of postoperative complications, transfusion rates, days in the hospital, readmission rates, and mortality.
Collapse
Affiliation(s)
- Fu-Qiang Zhang
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Yong-Ze Yang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China.
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China.
| | - Peng-Fei Li
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Guo-Rong Ma
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - An-Ren Zhang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Hui Zhang
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China
| | - Hong-Zhang Guo
- People's Hospital of Gansu Province, Chengguan District, 204 Donggang West Road, Lanzhou, 730000, China.
| |
Collapse
|
6
|
Dawod MS, Alswerki MN, Haddad BI, Alajlouni J, Alshrouf MA, Alnsour S, Dababseh S, Alsmairat MA. Intraoperative blood loss and haemoglobin drop in patients with developmental dysplasia of the hip in Jordan undergoing total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2023; 47:2933-2940. [PMID: 37341749 DOI: 10.1007/s00264-023-05869-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/11/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE Developmental dysplasia of the hip is still a prevailing secondary cause of early hip osteoarthritis in Jordan. Dysplastic coxarthrosis can result in significant and disabling hip pain with impaired patient's functionality. Due to this significant morbidity, patients ultimately need total hip arthroplasty, which offers the best functional outcome. Significant anatomical aberrances do exist in such hips as a result of old dysplasia; such pathoanatomical changes can complicate an already difficult surgery and lead to significant intraoperative blood loss and haemoglobin drop postoperatively. So, the aim of this research was to investigate on the intraoperative blood loos, and postoperative haemoglobin drop in these patients. METHODS A cross-sectional study design was adopted, and 162 patients with advanced hip osteoarthrosis secondary to developmental dysplasia of the hip (DDH) were studied. We studied predictors of hemoglobin drop and blood loss and linked some variables to this outcome variable using different statistical tests. RESULTS Our results showed a positive correlation between blood loss and BMI (r = 0.27, p = 0.73), haemoglobin drop and duration of surgery (r = 0.14, p = 0.07), length of hospital stay and duration of surgery (r = 0.25, p = 0.001). No significant differences between outcome measures (blood loss, haemoglobin drop, and duration of surgery) between males and females (p = 0.38, 0.93, 0.77 respectively). However, there was a statistically significant differences in haemoglobin drop among patients underwent general versus spinal anaesthesia (p = 0.03). additionally, there was a statistically significant association in length of hospital stay among smokers (p = 0.03), and patients who didn't prescribed anxiolytic preoperatively (p = 0.008). CONCLUSION Haemoglobin drop and blood loss in patients with dysplastic coxarthrosis were linked to increased preoperative BMI. Use of preoperative anxiolytics, and being non-smoker decreased the length of hospital stays. General anaesthesia was associated with more haemoglobin drop as well.
Collapse
Affiliation(s)
- Moh'd S Dawod
- Faculty of Medicine, Mutah University, Al-Karak, Jordan
| | - Mohammad N Alswerki
- Department of Orthopedics, Jordan University Hospital, P.O. Box: 13046, Amman, 11942, Jordan.
| | - Bassem I Haddad
- Department of Orthopedics, Jordan University Hospital, P.O. Box: 13046, Amman, 11942, Jordan
| | - Jihad Alajlouni
- Department of Orthopedics, Jordan University Hospital, P.O. Box: 13046, Amman, 11942, Jordan
| | | | | | | | | |
Collapse
|
7
|
Min L, Linyi Y, Chen L, Jiang S, Chen C. Preoperative moderate to severe anemia is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications: a propensity score-matched analysis in hip fracture surgery patients over 80 years old. Perioper Med (Lond) 2023; 12:56. [PMID: 37950304 PMCID: PMC10636975 DOI: 10.1186/s13741-023-00349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Anemia is a common health problem in the elderly. Preoperative anemia is a risk factor for postoperative outcomes in the elderly for hip fracture. The objective of the study was to explore the relationship between preoperative moderate to severe anemia and postoperative morbidity and mortality in hip fracture patients over 80 years old. METHODS We performed a retrospective cohort study exploring preoperative moderate to severe anemia and postoperative morbidity and mortality. Patients over 80 years old undergoing hip fracture surgery were included in the study. Data were collected for major adverse cardiac and cerebral events (MACCE), postoperative pulmonary complications (PPCs), in-hospital mortality, delirium, gastrointestinal complication, deep venous thrombus (DVT), acute renal failure, ICU admission, and perioperative transfusion > 2 units rate. RESULTS A total of 912 eligible patients were included for unmatched cohort analysis, and 512 patients were included for matched cohort analysis after propensity score matching. Baseline characteristics between the normal to mild anemia and moderate to severe anemia groups were significantly different. More patients in the moderate to severe cohort had a higher ASA classification grade III and female ratio. Patients in the moderate and severe anemia cohorts had more MACCE (unadjusted: odds ratio [OR] 1.968, 96% CI 1.090-3.555, P 0.023; adjusted: OR 1.929, 95% CI 1.014-3.668, P 0.045) and PPCs (unadjusted: OR 2.616, 95% CI 1.442-4.748, P 0.001; adjusted: OR 2.352, 95% CI 1.225-4.516, P 0.010) than patients with normal or mild anemia. However, the transfusion > 2 units rate was not significantly different between the two cohorts (unadjusted: OR 0.967, 95% CI 0.737-1.270, P 0.811; adjusted: OR 0.941, 95% CI 0.693-1.278, P 0.697). The in-hospital mortality, delirium rate, gastrointestinal complication, ICU admission, and DVT were similar. However, the in-hospital mortality was much higher (3.6%, 21/591 vs 1.6%, 5/321) in the moderate to severe anemia cohort. Furthermore, after propensity score-matched analysis, MACCE and PPCs were also significantly increased in the moderate to severe anemia cohort (OR 2.196 & 3.171, 95% CI 1.0794.470 & 1.563-6.436, P 0.027 & 0.001), which were in accordance with the unadjusted and adjusted results in the unmatched cohorts. CONCLUSIONS Moderate to severe preoperative anemia (< 11 g/dl) is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications. Additionally, in-hospital mortality was not significant but was higher in the preoperative moderate to severe anemia cohort. Preoperative assessment and correction of hemoglobin level to above 11 g/dl might reduce MACCE, PPCs, and in-hospital mortality in hip fracture patients over 80 years old.
Collapse
Affiliation(s)
- Li Min
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Yang Linyi
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Li Chen
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Shen Jiang
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Chen Chen
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China.
| |
Collapse
|
8
|
Schatz C, Plötz W, Beckmann J, Bredow K, Leidl R, Buschner P. Associations of preoperative anemia and postoperative hemoglobin values with hospital costs in total knee arthroplasty (TKA). Arch Orthop Trauma Surg 2023; 143:6741-6751. [PMID: 37306776 PMCID: PMC10258736 DOI: 10.1007/s00402-023-04929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Total knee arthroplasty are among the most frequently conducted surgeries, due to an aging society. Since hospital costs are subsequently rising, adequate preparation of patients and reimbursement becomes more and more important. Recent literature revealed anemia as a risk factor for enhanced length of stay (LOS) and complications. This study analyzed whether preoperative hemoglobin (Hb) and postoperative Hb were associated with total hospital costs and general ward costs. METHODS The study comprised 367 patients from a single high-volume hospital in Germany. Hospital costs were calculated with standardized cost accounting methods. Generalized linear models were applied to account for confounders, such as age, comorbidities, body mass index, insurance status, health-related quality of life, implant types, incision-suture-time and tranexamic acid. RESULTS Preoperative anemic women had 426 Euros higher general ward costs (p < 0.01), due to increased LOS. For men, 1 g/dl less Hb loss between the preoperative value and the value before discharge reduced total costs by 292 Euros (p < 0.001) and 161 Euros fewer general ward costs (p < 0.001). Total hospital costs were reduced by 144 Euros with 1 g/dl higher Hb on day 2 postoperatively for women (p < 0.01). CONCLUSION Preoperative anemia was associated with increased general ward costs for women and Hb loss with decreasing total hospital costs for men and women. Cost containment, especially reduced utilization of the general ward, may be feasible with the correction of anemia for women. Postoperative Hb values may be a factor for adjustments of reimbursement systems. LEVEL OF EVIDENCE Retrospective cohort study, III.
Collapse
Affiliation(s)
- Caroline Schatz
- Ludwig-Maximilians-Universität München, LMU Munich School of Management, Institute for Health Economics and Health Care Management, Ludwigstr. 28, 80539, Munich, Germany.
- Helmholtz Zentrum München, Institute for Health Economics and Health Care Management, Munich, Germany.
- Environmental Health Center at Helmholtz Munich, Munich, Germany.
| | - Werner Plötz
- Krankenhaus Barmherzige Brüder München, Akademisches Lehrkrankenhaus der Technischen Universität München, Munich, Germany
- Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Orthopaedic Praxis Munich-Nymphenburg, Munich, Germany
| | - Johannes Beckmann
- Krankenhaus Barmherzige Brüder München, Akademisches Lehrkrankenhaus der Technischen Universität München, Munich, Germany
| | - Katharina Bredow
- Helmholtz Zentrum München, Institute for Health Economics and Health Care Management, Munich, Germany
| | - Reiner Leidl
- Ludwig-Maximilians-Universität München, LMU Munich School of Management, Institute for Health Economics and Health Care Management, Ludwigstr. 28, 80539, Munich, Germany
- Helmholtz Zentrum München, Institute for Health Economics and Health Care Management, Munich, Germany
| | - Peter Buschner
- Krankenhaus Barmherzige Brüder München, Akademisches Lehrkrankenhaus der Technischen Universität München, Munich, Germany
| |
Collapse
|
9
|
Labott JR, Lu Y, Salmons HI, Camp CL, Wyles CC, Taunton MJ. Health and Socioeconomic Risk Factors for Unplanned Hospitalization Following Ambulatory Unicompartmental Knee Arthroplasty: Development of a Patient Selection Tool Using Machine Learning. J Arthroplasty 2023; 38:1982-1989. [PMID: 36709883 DOI: 10.1016/j.arth.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Identifying ambulatory surgical candidates at risk for adverse surgical outcomes can optimize outcomes. The purpose of this study was to develop and internally validate a machine learning (ML) algorithm to predict contributors to unexpected hospitalizations after ambulatory unicompartmental knee arthroplasty (UKA). METHODS A total of 2,521 patients undergoing UKA from 2006 to 2018 were retrospectively evaluated. Patients admitted overnight postoperatively were identified as those who had a length of stay ≥ 1 day were analyzed with four individual ML models (ie, random forest, extreme gradient boosting, adaptive boosting, and elastic net penalized logistic regression). An additional model was produced as a weighted ensemble of the four individual algorithms. Area under the receiver operating characteristics (AUROC) compared predictive capacity of these models to conventional logistic regression techniques. RESULTS Of the 2,521 patients identified, 103 (4.1%) required at least one overnight stay following ambulatory UKA. The ML ensemble model achieved the best performance based on discrimination assessed via internal validation (AUROC = 87.3), outperforming individual models and conventional logistic regression (AUROC = 81.9-85.7). The variables determined most important by the ensemble model were cumulative time in the operating room, utilization of general anesthesia, increasing age, and patient residency in more urban areas. The model was integrated into a web-based open-access application. CONCLUSION The ensemble gradient-boosted ML algorithm demonstrated the highest performance in identifying factors contributing to unexpected hospitalizations in patients receiving UKA. This tool allows physicians and healthcare systems to identify patients at a higher risk of needing inpatient care after UKA.
Collapse
Affiliation(s)
- Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab (OSAIL), Mayo Clinic, Rochester, Minnesota
| | - Harold I Salmons
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab (OSAIL), Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab (OSAIL), Mayo Clinic, Rochester, Minnesota
| | - Michael J Taunton
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; Department of Orthopedic Surgery, Orthopedic Surgery Artificial Intelligence Lab (OSAIL), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
10
|
Harris AB, Badin D, Hegde V, Oni JK, Sterling RS, Khanuja HS. Preoperative Anemia is an Independent Risk Factor for Increased Complications and Mortalities After Total Knee Arthroplasty Regardless of Postoperative Transfusions. J Arthroplasty 2023; 38:S177-S181. [PMID: 36736931 DOI: 10.1016/j.arth.2023.01.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Preoperative anemia is associated with adverse events following total knee arthroplasty (TKA). It remains unknown if this effect is due to comorbid conditions, adverse events associated with transfusions, or the anemia itself. We used propensity-score matching to isolate the effect of anemia on postoperative complications following TKA, regardless of blood transfusions. METHODS Patients undergoing primary TKA from 2010 to 2020 without receiving a perioperative blood transfusion, were identified using a large national database. A 1:1 propensity score matching was used to create cohorts of anemic and nonanemic patients matched on Charlson Comorbidity Index (CCI), American Society of Anesthesiology (ASA) classification, age, sex, and prevalence of bleeding disorders. There were 43,370 patients were included in each group (mean age 68 [range, 29 to 99; 44% male]). The 1:1 matching yielded groups with similar CCI, ASA classification, age, sex, and prevalence of bleeding disorders (all, P > .9). RESULTS Anemic patients had a higher incidence of major complications (4.1 versus 2.8%; P < .001), 30-day mortality rate (0.2 versus 0.1%; P < .001), and extended lengths of stay (LOS) (8.3 versus 6.6%; P < .001). Anemic patients also had increased 30-day rates of wound infection requiring hospital admission, renal failure, reintubation, myocardial infarction, and pneumonia (all, P < .001). CONCLUSION In matched cohorts of anemic versus nonanemic patients undergoing TKA, all who had no postoperative blood transfusion, anemic patients had higher rates of complications, extended LOS, and mortalities. Thus, anemia should be considered an independent risk factor for complications following TKA.
Collapse
Affiliation(s)
- Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Daniel Badin
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
11
|
Li M, Chen C, Shen J, Yang L. Preoperative Hemoglobin <10 g/DL Predicts an Increase in Major Adverse Cardiac Events in Patients With Hip Fracture Over 80 Years: A Retrospective Cohort Study. Geriatr Orthop Surg Rehabil 2023; 14:21514593231183611. [PMID: 37334252 PMCID: PMC10272637 DOI: 10.1177/21514593231183611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023] Open
Abstract
Background Preoperative anemia has been associated with perioperative morbidity and mortality in patients undergoing cardiac and non-cardiac surgery. Preoperative anemia is common in elderly hip fracture patients. The primary objective of the study was to explore the relationship between preoperative hemoglobin levels and postoperative major adverse cardiovascular events (MACEs) in hip fracture patients over 80 years. Methods The retrospective study enrolled hip fracture patients over 80 years from January 2015 to December 2021 in our center. The data were collected from the hospital's electronic database after approval by the ethics committee. The primary objective of the study was to investigate MACEs, and the secondary objectives included in-hospital mortality, delirium, acute renal failure, ICU admission rate, and transfusion (>2 U). Results 912 patients were entered for final analysis. Based on the restricted cubic spline, the risk of preoperative hemoglobin (<10 g/DL) was associated with an increased risk of postoperative complications. With univariable logistic analysis, a hemoglobin level <10 g/DL was associated with increased MACEs [OR 1.769, 95% CI (1.074, 2.914), P = .025], in-hospital mortality [OR 2.709, 95% CI (1.215, 6.039), P = .015] and transfusion >2 U risk [OR 2.049, 95% CI (1.56, 2.69), P < .001]. Even after adjustment for confounding factors, MACEs [OR 1.790, 95% CI (1.073, 2.985), P = .026], in-hospital mortality [OR 2.81, 95% CI (1.214, 6.514), P = .016] and transfusion >2 U rate [OR 2.002, 95% CI (1.516, 2.65), P < .001] were still higher in the lower hemoglobin level cohort. Moreover, a log-rank test showed increased in-hospital mortality in the cohort with a preoperative hemoglobin level of <10 g/DL. However, there was no difference in delirium, acute renal failure, and ICU admission rates. Conclusions In conclusion, for hip fracture patients over 80 years, preoperative hemoglobin levels <10 g/DL might be associated with increased postoperative MACEs, in-hospital mortality, and transfusion >2 U.
Collapse
Affiliation(s)
- Min Li
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Chen Chen
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Jiang Shen
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Linyi Yang
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| |
Collapse
|
12
|
Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:1643-1650. [PMID: 35195782 DOI: 10.1007/s00402-022-04391-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty. METHODS A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis. CONCLUSION This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning. LEVEL OF EVIDENCE III, case-control retrospective analysis.
Collapse
|
13
|
Perez Alamino L, Tillet F, Bochatey E, Lopreite F. Optimización preoperatoria del paciente antes de una artroplastia de cadera o rodilla: parte 1. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.5.1658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Las artroplastias de cadera y rodilla son estrategias que han demostrado ser efectivas en el tratamiento de la patología degenerativa articular. El reemplazo articular mejora la calidad de vida de la mayoría de los pacientes cuando el tratamiento conservador falla. Sin embargo, estas son cirugías mayores que conllevan un riesgo significativo de complicaciones, incluyendo la necesidad de una revisión. El propósito de este artículo es analizar los factores de riesgo modificables del paciente antes de la cirugía, a finde disminuir el riesgo de complicaciones posoperatorias. Estudios recientes han descripto ciertos factores de riesgo modificables, inherentes al paciente y que incrementan la posibilidad de complicaciones posoperatorias luego de un reemplazo articular de cadera o rodilla. Estos incluyen obesidad, malnutrición, tabaquismo, diabetes, anemia, deficiencia de vitamina D, consumo de opioides, artropatías inflamatorias, insuficiencia renal crónica y colonización por estafilococco meticilino-resistente. Si conseguimos optimizar estas condiciones durante el preoperatorio, reduciremos el riesgo de complicaciones posoperatorias.
Collapse
|
14
|
Abstract
Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.
Collapse
|
15
|
Cao G, Yang X, Xu H, Yue C, Huang Z, Zhang S, Quan S, Yao J, Yang M, Pei F. Association between preoperative hemoglobin and postoperative moderate and severe anemia among patients undergoing primary total knee arthroplasty: a single-center retrospective study. J Orthop Surg Res 2021; 16:572. [PMID: 34565418 PMCID: PMC8474733 DOI: 10.1186/s13018-021-02727-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Postoperative moderate and severe anemia (PMSA) has been a serious perioperative complication in primary total knee arthroplasty (TKA). However, the ideal cutoff values to predict PMSA is still undetermined. The aim of this study was (1) to identify the risk factors associated with PMSA and (2) to establish the cutoff values of preoperative hemoglobin (HB) associated with increased PMSA in primary TKA. METHODS We identified 474 patients undergoing primary TKA and separated those in which PMSA (HB was less than 110 g/L on postoperative day 1 and 3) was developed from those without PMSA. Multivariate logistic regression model was used to identify independent risk factors for PMSA. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative HB cutoff across all the patients. RESULTS The PMSA rate in primary TKA was 53.2%. Significant risk factors were lower preoperative HB (OR [odds ratio] = 1.138, 95% CI [confidence interval] = 1.107-1.170, p < 0.001) and more intraoperative blood loss (OR = 1.022, 95% CI 1.484-4.598, p < 0.001). A preoperative HB cutoff value that maximized the AUC was 138.5 g/L for men (sensitivity: 79.4%, specificity: 75.0%) and 131.5 g/L for women (sensitivity: 74.7%, specificity: 80.5%), respectively. CONCLUSION We should recognize and consider the related risk factors to establish specific, personalized risk assessment for PMSA, including preoperative HB and intraoperative blood loss. Of these, preoperative HB was a referable tool to predict PMSA in primary TKA.
Collapse
Affiliation(s)
- Guorui Cao
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Xiuli Yang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Chen Yue
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, 621000, Sichuan Province, People's Republic of China
| | - Songtao Quan
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Junna Yao
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Minglu Yang
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
| |
Collapse
|