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Gong MF, McElroy MJ, Li WT, Finger LE, Shannon M, Gabrielli AS, Tisherman RF, O'Malley MJ, Klatt BA, Plate JF. Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty. J Arthroplasty 2024; 39:1468-1473. [PMID: 38040065 DOI: 10.1016/j.arth.2023.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. METHODS A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. RESULTS Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. CONCLUSIONS The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matthew F Gong
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark J McElroy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William T Li
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Logan E Finger
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael Shannon
- The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alexandra S Gabrielli
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert F Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael J O'Malley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian A Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Anastasio AT, Kim BI, Cochrane NH, Belay E, Bolognesi MP, Talaski GM, Ryan SP. Higher Risk of Reoperation after Total Knee Arthroplasty in Young and Elderly Patients. MATERIALS (BASEL, SWITZERLAND) 2023; 16:7012. [PMID: 37959609 PMCID: PMC10648704 DOI: 10.3390/ma16217012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/30/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40-49 years), middle (50-79 years), and elderly (80-89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays (p < 0.001) but longer operative times (p < 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia (p < 0.001), acute renal failure (p < 0.001), stroke (p < 0.001), cardiac arrest (p < 0.001), and transfusions (p < 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% (p < 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.
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Affiliation(s)
- Albert T. Anastasio
- Department of Orthopedic Surgery, Duke University, Durham, NC 27707, USA; (A.T.A.); (N.H.C.); (E.B.); (M.P.B.); (S.P.R.)
| | - Billy I. Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, NY 10021, USA;
| | - Niall H. Cochrane
- Department of Orthopedic Surgery, Duke University, Durham, NC 27707, USA; (A.T.A.); (N.H.C.); (E.B.); (M.P.B.); (S.P.R.)
| | - Elshaday Belay
- Department of Orthopedic Surgery, Duke University, Durham, NC 27707, USA; (A.T.A.); (N.H.C.); (E.B.); (M.P.B.); (S.P.R.)
| | - Michael P. Bolognesi
- Department of Orthopedic Surgery, Duke University, Durham, NC 27707, USA; (A.T.A.); (N.H.C.); (E.B.); (M.P.B.); (S.P.R.)
| | | | - Sean P. Ryan
- Department of Orthopedic Surgery, Duke University, Durham, NC 27707, USA; (A.T.A.); (N.H.C.); (E.B.); (M.P.B.); (S.P.R.)
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Hummel A, Gaucher D, Wang P, Lawton DRY, Andrews SN, Nakasone CK. Higher intra-operative narcotic requirements and weakness with quadratus lumborum compared to paravertebral nerve block for total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:6849-6855. [PMID: 37269351 DOI: 10.1007/s00402-023-04925-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/21/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND This was a prospective single-blinded study comparing the peri-operative opioid consumption and motor weakness for patients undergoing total hip arthroplasty (THA) with either a Quadratus Lumborum Type 3 Nerve Block (QLB) or a Paravertebral Nerve Block (PVB). METHODS A consecutive cohort of patients undergoing elective anterior approach (AA) THA by a single high-volume surgeon were randomly assigned an anesthesiologist by the charge anesthesiologist. One anesthesiologist performed all QLBs, and the other six anesthesiologists performed the PVBs. Pertinent data include prospectively collected qualitative surveys from blinded medical personnel, floor nurses, and physical therapists as well as demographic information and post-operative complications. RESULTS Overall, 160 patients were included in the study divided equally between the QLB and PVB groups. The QLB group had a statistically higher peri-operative narcotic use (p < 0.001), greater intra-operative peak systolic blood pressure (p < 0.001) and respiratory rate (p < 0.001), and higher incidence of post-operative lower extremity muscle weakness (p = 0.040). There were no statistical group differences for floor narcotic use, post-operative hemoglobin levels or hospital length of stay. CONCLUSION The QLB required greater intraoperative narcotic use and resulted in greater post-operative weakness, however provided nearly equal post-operative pain management and did not adversely affect rapid discharge success. LEVEL OF EVIDENCE III, Non-randomized controlled cohort/follow-up study.
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Affiliation(s)
- Amelia Hummel
- John A Burns School of Medicine., University of Hawai'I, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Donald Gaucher
- Department of Orthopedic Surgery, Straub Medical Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Peter Wang
- Department of Orthopedic Surgery, Straub Medical Center, 888 South King Street, Honolulu, HI, 96813, USA
| | - Dylan R Y Lawton
- John A Burns School of Medicine., University of Hawai'I, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Samantha N Andrews
- Department of Orthopedic Surgery, Straub Medical Center, 888 South King Street, Honolulu, HI, 96813, USA
- Department of Kinesiology and Rehabilitation Science, University of Hawai'I, 1337 Lower Campus Road, Honolulu, HI, 96822, USA
| | - Cass K Nakasone
- Department of Orthopedic Surgery, Straub Medical Center, 888 South King Street, Honolulu, HI, 96813, USA.
- Department of Surgery, John A Burns School of Medicine, University of Hawai'I, 1356 Lusitana Street, Honolulu, HI, 96813, USA.
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Rodriguez S, Shen TS, Lebrun DG, Della Valle AG, Ast MP, Rodriguez JA. Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors. Bone Jt Open 2022; 3:684-691. [PMID: 36047458 PMCID: PMC9533240 DOI: 10.1302/2633-1462.39.bjo-2022-0106.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aims The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691.
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Affiliation(s)
- Samuel Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Tony S. Shen
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Drake G. Lebrun
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Alejandro G. Della Valle
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Michael P. Ast
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Jose A. Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
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