Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs

Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

BACKGROUND

Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined.

QUESTIONS/PURPOSES

When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition?

METHODS

An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming.

RESULTS

After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33).

CONCLUSION

Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Advanced Multi-Layer Watertight Closure versus Conventional Closure in Total Hip and Knee Replacement Surgery

Background

In total joint replacement procedures, surgeons have increasingly adopted advanced multi-layer, watertight closure. The objective of the study was to compare the clinical and economic outcomes for advanced multi-layer, watertight closure patients to those with conventional closure with sutures and skin staples.

Methods

Patients aged ≥18 years were included in the study if they underwent total joint arthroplasty of the hip or knee as an elective, primary, inpatient procedure between January 2014 and March 2019. Cohorts having advanced multi-layer, watertight closure or conventional closure were compared using multivariable regression analysis of surgical site infections, length of stay, operating room time, procedure time, discharge status, readmissions, reoperations, and hospital emergency department visits.

Results

A total of 1828 patients received at least one total hip or knee replacement, of which 434 (23.7%) had advanced multi-layer, watertight closure and 1394 (76.3%) had conventional closure. Unadjusted time to readmission, when occurring, was considerably longer following advanced multi-layer, watertight closure (89.9 vs 51.1 days, p < 0.0001), and a lower proportion of the advanced multi-layer, watertight closure cohort required reoperation within 90 days (0.0% vs 2.6%, p < 0.0001). Adjusted mean hospital length of stay was approximately half of a day shorter for advanced multi-layer, watertight closure patients (1.10 vs 1.65 days; p < 0.001), and they were also more likely to be discharged to home (Odds Ratio: 4.61; p = 0.002).

Conclusion

Among patients undergoing total hip and knee arthroplasty in a highly optimized real-world clinical practice, advanced multi-layer, watertight closure was associated with significantly shorter inpatient length of stay and increased likelihood of being discharged to home compared with conventional closure. These findings suggest that advanced multi-layer, watertight closure is a valuable component of an optimal workflow for total hip or knee replacement, and may be especially valuable for high-risk patients.

Complication Rates Are Not Higher After Outpatient Versus Inpatient Fast-Track Total Knee Arthroplasty: A Propensity-Matched Prospective Comparative Study

BACKGROUND

This prospective study aimed to compare the complication rates and clinical outcomes of propensity-matched patients who received fast-track total knee arthroplasty (FT TKA) in outpatient versus inpatient settings.

METHODS

Patients (n = 629) who received FT TKA at various outpatient (n = 176) and inpatient (n = 462) surgery rates were prospectively followed until 90 days after surgery. The decision between inpatient versus outpatient FT TKA was made on a case-by-case basis, depending on consultation between the surgeon and patient. Complications were collected to distinguish between intraoperative complications, complications with no readmission, complications with readmission, and complications with reoperation. Propensity scores based on age, sex, body mass index, and the American Society of Anesthesiologists score were used to match outpatient to inpatient FT TKA. A cumulative incidence function was computed by taking the time to diagnose any postoperative complication in the first 90 days as the end point.

RESULTS

Propensity score matching (1:2 ratio) for comparison resulted in 173 outpatient FT TKAs and 316 inpatient FT TKAs. No significant differences were observed between outpatient versus inpatient FT TKA for intraoperative complication rates (2% in both groups). At 90-day follow-up, no significant differences were observed between outpatient versus inpatient FT TKA for total complications with no readmission (8.0 versus 7.9%), complications with readmission but no reoperation (1.1 versus 0.6%), and complications with reoperation (4.0 versus 4.4%). A comparison of postoperative complication diagnosis time using the cumulative incidence function revealed no significant differences between outpatient versus inpatient FT TKA.

CONCLUSIONS

The present study revealed that there were no differences in 90-day postoperative complication rates between outpatient and inpatient FT TKA and that there were also no differences in rates of intraoperative complications, readmissions, or reoperations. These findings may encourage hesitant surgeons to move toward outpatient TKA pathways, as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

LEVEL OF EVIDENCE

Level II.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7] years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p < 0.05), 44% lower LOS (1.4 vs 2.5 days, p < 0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p < 0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90 days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9 days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Impact of fast-track rehabilitation nursing on pressure ulcers and postoperative complications in patients with inter-trochanteric fractures: A meta-analysis

We sought to investigate the effects of fast-track rehabilitation nursing on pressure ulcers, length of hospital stay and postoperative complications in patients with inter-trochanteric fractures (ITF). The PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure and WanFang databases were searched for randomised controlled trials (RCTs) published from inception to September 2023 on the application of fast-track rehabilitative nursing to ITF. Two investigators independently screened the literature and performed data extraction and quality assessments using the Cochrane Risk of Bias Assessment Tool. The meta-analysis was performed using RevMan 5.4. Overall, 22 RCTs involving 1904 patients were included. Meta-analysis revealed that after fast-track rehabilitation nursing intervention in patients with ITF, the occurrence of pressure ulcers (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.18-0.47; p < 0.001) and postoperative complications (OR: 0.19; 95% CI: 0.14-0.26; p < 0.001) were significantly reduced and hospital stay was significantly shorter (standardised mean difference: -3.10; 95% CI: -3.82 to -2.38; p < 0.001). Nursing care for patients with ITF based on the concept of fast-track rehabilitation is conducive to reducing the occurrence of pressure ulcers, lowering the occurrence of complications, shortening the length of hospitalisation and promoting postoperative rehabilitation.

Factors affecting the length of hospital stay for total knee arthroplasty in Japan: a retrospective study using the diagnosis procedure combination database

BACKGROUND

We aimed to evaluate the length of hospital stay following total knee arthroplasty to determine the impact of relevant factors using data from the Diagnosis Procedure Combination database.

METHODS

This was a retrospective observational study. The study cohort included 5,831 patients who had osteoarthritis of the knee and had undergone total knee replacement between February 2018 and October 2022 at 38 hospitals.

RESULTS

Multivariate analysis showed that the factors influencing the length of stay included: age (p < 0.001), height (p < 0.001), weight (p = 0.049), body mass index (p = 0.008), Barthel index (p < 0.001), method of anesthesia (p < 0.001), bone transplant (p = 0.010), timing of postoperative rehabilitation (p < 0.001), atrial fibrillation (p < 0.001), chronic pain (p < 0.001), and number of institutionally treated cases (p < 0.001) (r = 0.451, p < 0.001).

CONCLUSIONS

Shorter or longer hospital stays were found to be associated with the patients' background characteristics and facility-specific factors; these can lead to more accurate estimates of the length of hospital stay and appropriate allocation of resources.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BACKGROUND

Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.

OBJECTIVE

This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.

MATERIALS AND METHODS

All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.

RESULTS

In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).

CONCLUSION

Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

BACKGROUND

Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.

METHODS

A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.

RESULTS

Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).

CONCLUSIONS

There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.

Patient information pathway in orthopedic surgery: Roles of ERAS and pharmacists

INTRODUCTION

Enhanced Rehabilitation After Surgery (ERAS) pathways significantly improve the care of patients in orthopedic surgery. However, patient knowledge and memorization of the information provided are currently poorly documented.

HYPOTHESIS

The information provided by a postoperative pharmacist could have a positive impact on patient care, in particular by improving knowledge about their prosthesis.

MATERIAL AND METHOD

This prospective feasibility study included a cohort of 80 patients operated on for a hip or knee prosthesis and who received postoperative pharmacist interviews (POPI). These POPIs informed the patient about the prosthesis, the complications, positions to avoid, as well as the postoperative follow-up. The objective was to measure the patient's knowledge before and after the POPI. Qualitative and quantitative analyses, by indication and patient pathway, were performed.

RESULTS

The patient's knowledge before POPI was 70% correct. After POPI this rate rose to 91%.

DISCUSSION

Patients' knowledge was weak and heterogeneous, especially regarding the implanted prosthesis. The POPI led to significant improvement and standardization of knowledge which should contribute to the prevention of iatrogenic harm (positions to avoid, infection prevention, compliance with analgesics and anticoagulants).

CONCLUSION

A POPI with a pharmacist improves overall patient management during hip or knee arthroplasty.

LEVEL OF EVIDENCE

III; non-randomized prospective feasibility study.

The relationship between preoperative anemia and length of hospital stay among patients undergoing radical surgery for esophageal carcinoma: a single-centre retrospective study

BACKGROUND

Although it is unclear if preoperative anemia affects patients undergoing radical resection of esophageal cancer, it does increase the length of stay (LOS) for surgical patients. Accordingly, the purpose of this study was to investigate if, after adjusting for other covariates, anemia was independently associated with LOS in people undergoing radical resection of esophageal cancer.

METHODS

The retrospective cohort study included 680 patients undergoing radical esophageal cancer surgery between January 2010 and December 2020. Preoperative anemia was the targeted independent variable, while LOS was the target independent variable. Demographics, comorbidities, laboratory tests, surgery and anesthesia, postoperative outcomes, and complications were collected. Multivariate linear analyses were performed for variables that might influence preoperative anemia and LOS selection. Subgroup analysis using hierarchical variables was then used to test the potential relationship.

RESULTS

The 647 individuals that were randomly chosen had an average age of 61.06 ± 8.16 years, and 77.43% of them were male. The prevalence of anemia was 36.6%. All patients recruited had an average length of stay (LOS) of 26.31 ± 13.19 days, 25.40 ± 11.44 days for patients who had no preoperative anemia, and 27.89 ± 15.66 days for patients who had preoperative anemia, p < 0.05. After adjusting for covariates, the results of fully adjusted linear regression revealed that preoperative anemia was significantly associated with LOS (β = 2.04, 95%CI (0.13, 3.96) ), p < 0.05. The results of the subgroup analysis were basically accurate and steady. Regardless of gender, same outcomes were seen when preoperative anemia was defined as a Hb level < 13 g/dL (β = 2.29, 95%CI (0.33, 4.25) ), p < 0.05. In addition, the LOS was shortened with the increase of preoperative hemoglobin (Hb) (β= -0.81, 95%CI (-1.46, -0.1) ), p < 0.05.

CONCLUSION

Preoperative anemia is typical in Chinese patients undergoing radical esophageal cancer resection and is independently associated with prolonged LOS.

No clinically significant difference in postoperative pain and side effects comparing conventional and enhanced recovery total hip arthroplasty with early mobilization

INTRODUCTION

Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively.

METHODS

In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the "Quality Improvement in Postoperative Pain Treatment project" (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively.

RESULTS

The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05).

CONCLUSION

This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

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.

Modifiable factors influencing length of stay after total knee arthroplasty

PURPOSE

This cohort study aims to investigate the current Rapid-Recovery-(RR)-pathway at an orthopaedic surgery hospital centre and to identify preoperative, intraoperative, and postoperative factors that are significantly associated with prolonged hospital Length of Stay (LOS) after total knee arthroplasty (TKA).

METHOD

A total of 194 patients undergoing primary TKA were included in this retrospective study. Sociodemographic data documented were age, gender, body mass index, living situation, and the clinical diagnosis. Factors affecting patient constitution and laboratory data for serum level of Hb and CRP were assessed preoperatively and postoperatively. In addition, we collected patients' data for attendance of patient education, planned discharge to rehabilitation facilities, and levels of postoperative pain.

RESULTS

In univariate group comparisons, prolonged LOS was significantly associated with increased age, elevated C-reactive-Protein-level, and decreased haemoglobin level. Patients experiencing prolonged LOS also showed significant association with higher prevalence of comorbidities, female gender, living as widow, preoperative anticoagulation, requirement of blood transfusion, and planned discharge to rehabilitation facilities. However, after multivariate logistic regression, only planned discharge to rehabilitation facility, non-attendance of preoperative patient education, female gender, and increased pain levels were identified as significant predictors for prolonged LOS.

CONCLUSION

Efficient pain therapy and thorough patient education have a positive effect on treatment outcome after TKA in a RR-setting.

Anterior Approach to Hip Arthroplasty with Early Mobilization Key for Reduced Hospital Length of Stay

Background and Objectives: This study aimed to explore the preoperative factors related to early mobilization and length of stay (LOS) after total hip arthroplasty and the benefits of the anterior approach over the traditional lateral approach. Materials and Methods: Every patient benefits from information regarding details of the surgery approach, possible intra, and postoperative complications, post-operator medical care, and steps in the early mobilization protocol. The patient underwent a pre-anesthetic evaluation, was checked for preoperatory vital function, and was reevaluated for mobilization at 6, 12, 24, 36, 48, and 96 h after total hip arthroplasty using the anterior versus lateral approach. Results: The result of the statistical calculations indicates the independent negative risk factors for reaching the mobilization target: age with a coefficient of -0.046, p = 0.0154 and lateral approach with a relative risk of 0.3802 (95% CI: 0.15-0.90), p = 0.0298. Statistical data concerning the length of stay (LOS) showed significant differences in the total days spent in the hospital. The patients who were operated on using the lateral approach presented a higher body mass index than those with the anterior approach, but this difference did not reach the threshold of statistical significance. Conclusions: In our study, patient mobilization is crucial to reduce LOS.

The effect of pharmacist-initiated perioperative multidisciplinary pharmaceutical care model and clinical pathway on pain management in patients undergoing orthopedic surgery: a before-after study

BACKGROUND

Poor pain control is common in perioperative orthopedic surgeries. However, there is a lack of exploration of the clinical pharmacy practice model for this population.

AIM

To construct a perioperative pharmaceutical care model and clinical pathway for patients undergoing orthopedic surgeries and assess their impact on pain management.

METHOD

This historical before-and-after study was conducted in the Department of Orthopedics of a tertiary hospital in Guangdong Province, China. The control group was surgical patients who received routine diagnosis and treatment. The intervention group received pain management from a multidisciplinary team based on a pharmacist-initiated pharmaceutical care practice model and clinical pathways for medication management. The primary outcome measures were postoperative pain at rest (PAR) and movement-evoked pain (MEP) scores, number of breakthrough pains, and length of hospital stay.

RESULTS

A total of 320 orthopedic surgery patients were included. Among patients with expected moderate or severe postoperative pain (82.5%), significantly lower PAR and MEP scores were observed in the intervention group 24 h after surgeries compared to the control group (p < 0.05). Compared to the control group, hospital stay in the intervention group was shortened by 2.3 days (p < 0.001). However, there were no significant differences in the control of breakthrough pain and the incidence of adverse drug reactions (p > 0.05).

CONCLUSION

Multidisciplinary perioperative pain management practice models and clinical pathways initiated by pharmacists could improve outcome indicators related to pain management and support the role and value of pharmacists.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

BACKGROUND

Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA.

METHODS

We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed.

RESULTS

Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS.

CONCLUSIONS

ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study

Purpose

Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH).

Methods

Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer.

Results

Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates.

Conclusion

Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture

BACKGROUND

Because of their poor physical state, elderly hip fracture patients commonly require prolonged hospitalization, resulting in a drop in bed circulation rate and an increased financial burden. There are currently few predictive models for delayed hospital discharge for hip fractures. This research aimed to develop the optimal model for delayed hospital discharge for hip fractures in order to support clinical decision-making.

METHODS

This case-control research consisted of 1259 patients who were continuously hospitalized in the orthopedic unit of an acute hospital in Tianjin due to a fragility hip fracture between January and December 2021. Delayed discharge was defined as a hospital stay of more than 11 days. The prediction model was constructed through the use of a Cox proportional hazards regression model. Furthermore, the constructed prediction model was transformed into a nomogram. The model's performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). the STROBE checklist was used as the reporting guideline.

RESULTS

The risk prediction model developed contained the Charlson Comorbidity Index (CCI), preoperative waiting time, anemia, hypoalbuminemia, and lower limbs arteriosclerosis. The AUC for the risk of delayed discharge was in the training set was 0.820 (95% CI,0.79 ~ 0.85) and 0.817 in the testing sets. The calibration revealed that the forecasted cumulative risk and observed probability of delayed discharge were quite similar. Using the risk prediction model, a higher net benefit was observed than when considered all patients were at high risk, demonstrating good clinical usefulness.

CONCLUSION

Our prediction models could support policymakers in developing strategies for the optimal management of hip fracture patients, with a particular emphasis on individuals at high risk of prolonged LOS.

Postoperative outcomes and anesthesia type in total knee arthroplasty in patients with obstructive sleep apnea

Aim: We investigated the relationship between obstructive sleep apnea (OSA), 30/90-day readmission rates and perioperative complications (postoperative cardiovascular, gastrointestinal, infectious or intraoperative complications) in patients undergoing total knee arthroplasty. Materials & methods: We analyzed records of patients who underwent total knee arthroplasty using State Inpatient Databases. Demographics, comorbidities, 30/90-day readmission rates and complications were compared by OSA status. For NY, USA we analyzed outcomes by anesthetic type (regional vs general). Results: OSA patients were mostly male, had more comorbidities and had increased 30/90-day readmission rates. There were no differences in complications. In NY, there were no differences in outcomes by anesthetic type. Conclusion: OSA was associated with increased 30/90-day readmission rates. Within NY, anesthetic type was not associated with any outcomes.

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery.

MATERIAL AND METHODS

A multidisciplinary group created the programme and the patient school (preoperative consultations where the patients' surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D).

RESULTS

One hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively.

CONCLUSIONS

The ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.

Surgical solutions for preoperative skin preparation in total hip arthroplasty: A cost-effectiveness analysis of Betadine® and Chloraprep™

OBJECTIVE

The purpose of our study was to compare the cost of surgical site skin preparation using ChloraPrep™ (2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) with skin cleansing using Betadine® Surgical Scrub and Betadine® 5% solution (povidone-iodine [PVI]) in total hip arthroplasty (THA).

HYPOTHESIS

The hypothesis was that the ChloraPrep™ skin disinfection protocol reduces the cost of perioperative antisepsis.

METHODS

A prospective database was created for all THAs performed at our university hospital between November 1st, 2020, and December 31st, 2020. Each surgeon was randomly assigned one type of antiseptic prior to the start of the study: one surgeon to the ChloraPrep™ group and one to the Betadine® group. In both groups, the enrollment stopped at the 15th patient. The costs related to consumables, waste disposal, and operating room occupancy time of each protocol were then assessed for each patient.

RESULTS

The mean duration of the ChloraPrep™ protocol was 3.5±0.3minutes compared to 13.5±0.9minutes for the Betadine® protocol. The overall cost of a surgical site skin preparation involving all three steps was on average €46.8±4.2 for the ChloraPrep™ group compared to €155±10.9 for the Betadine® group (p<0.0001).

DISCUSSION

Not only is the effectiveness of ChloraPrep™ already recognized but it also appears to have health economic benefits. However, further studies are needed to confirm this finding.

LEVEL OF EVIDENCE

III, case control study.

Improved clinical outcomes of outpatient enhanced recovery hip and knee replacements in comparison to standard inpatient procedures: A study of patients who experienced both

BACKGROUND

The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. This study's main objective was to evaluate adverse events with an ERAS-outpatient compared to standard-inpatient care and secondary objectives were to compare pain, functional recovery, PROMs and satisfaction.

HYPOTHESIS

The ERAS-outpatient program would result in reduced adverse events compared to standard-inpatient care.

METHODS

An ambidirectional single subject cohort study was conducted on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). Adverse event rate according to the Clavien-Dindo scale, the Comprehensive Complications Index (CCI) and the number of unplanned episodes of care were assessed. Postoperative pain on a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient reported outcome measures (PROMs) (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated.

RESULTS

Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs. 4.4, p<0.001), CCI was significantly lower (12.3 vs. 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs. 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p>0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p<0.002).

CONCLUSION

Compared to the conventional inpatient care, the ERAS-outpatient program proved to be safer, enable faster functional recovery, and improve patients' satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program.

LEVEL OF EVIDENCE

III; Ambidirectional Cohort study.

Outpatient total knee and hip arthroplasty present comparable and even better clinical outcomes than inpatient operation

Background

The purpose of this study was to compare total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days after outpatient and standard inpatient total knee and total hip arthroplasty (TKA, THA).

Methods

A literature search was conducted from the PubMed, Cochrane Library, and Embase databases for articles published before 20 August 2021. The types of studies included prospective randomized controlled trials, prospective cohort studies, retrospective comparative studies, retrospective reviews of THA and TKA registration databases, and observational case-control studies. Comparisons of interest included total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days. The statistical analysis was performed using Review Manager 5.3.

Results

Twenty studies with 582,790 cases compared relevant postoperative indicators of outpatient and inpatient total joint arthroplasty (TJA) (TKA and THA). There was a significant difference in the total complications at 30 days between outpatient and inpatient THA (p = 0.001), readmissions following TJA (p = 0.03), readmissions following THA (p = 0.001), stroke/cerebrovascular incidents following TJA (p = 0.01), cardiac arrest following TJA (p = 0.007), and blood transfusions following TJA (p = 0.003). The outcomes showed an obvious difference in 90-day total complications between outpatient and inpatient TJA (p = 0.01), readmissions following THA (p = 0.002), and surgical-related pain following TJA (p < 0.001). We did not find significant differences in the remaining parameters.

Conclusion

Outpatient procedures showed comparable and even better outcomes in total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days compared with inpatient TJA for selected patients.

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Preoperative High Sleep Quality Predicts Further Decrease in Length of Stay after Total Joint Arthroplasty under Enhanced Recovery Short-stay Program: Experience in 604 Patients from a Single Team

Objective

To investigate the safety, efficiency and cost of total joint arthroplasty (TJA) under the enhanced recovery after surgery (ERAS) program and identify predictors facilitating further decrease in length of stay (LOS).

Methods

We retrospectively collected the information of patients who underwent primary unilateral TJA by a single surgical team between January 2017 and June 2019. A total of 604 patients with LOS ≤ 3 was enrolled in this study. All patients completed 12‐month or longer follow‐up. Patients received the same ERAS protocol, mainly including preoperative preparation (patient education, preoperative functional exercises, nutritional support), blood management, pain management, sleep management, prevention of infection, prevention of thrombosis and strict discharge criteria. Preoperative characteristics of patients were collected from the medical record system and were compared between the LOS ≤ 2 group and the LOS = 3 group. Factors with significant difference were included in multivariate logistic regression analysis to find independent preoperative predictors for LOS. Joint function at the latest follow‐up, adverse events rate and hospitalization costs were compared between the LOS ≤ 2 group and the LOS = 3 group.

Results

Of the enrolled 604 patients, 271 patients (44.9%) had a LOS of 2 days or less while 333 patients (55.1%) had a LOS of 3 days. Pittsburgh Sleep Quality Index score (odds ratio [OR] = 1.084, 95% confidence interval [CI] = 1.024–1.147, P = 0.005), preoperative albumin level (OR = 0.945, 95% CI = 0.905–0.988, P = 0.012), digestive diseases (OR = 1.084, 95% CI = 1.024–1.147, P = 0.005) and total hip arthroplasty (THA) (OR = 0.273, 95% CI = 0.170–0.439, P < 0.001) were predictors of LOS ≤ 2 in the multivariate logistic analysis model. The postoperative joint function scores and adverse event rates were comparable between the LOS ≤ 2 group and the LOS = 3 group. The hospital costs were lower in the LOS ≤ 2 group than the LOS = 3 group.

Conclusion

Under the rigorous ERAS program, 2‐day discharge in unselected TJA patients can be routinely applied. Patients with high preoperative sleep quality, high preoperative albumin level, free of digestive disease and undergoing THA procedure are more likely to be discharged within 2 days.

Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol

Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centers to focus on outpatient pathway implementation. However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved rehabilitation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. This article delivers a case for modernizing total hip arthroplasty perioperative pathways by implementing ERAS-outpatient protocols.

Hip and Knee Arthroplasty

Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.

Comparison of periarticular multidrug injection versus epidural catheter in 55 patients undergoing total hip arthroplasty: A prospective randomized controlled trial

INTRODUCTION

Epidural catheter (EC) and periarticular multidrug injection (PMDI) are widely performed for reducing total hip arthroplasty (THA) postoperative pain. However, the more effective analgesic technique between the two is unclear. Thus, we aimed to answer the following questions: (1) does PMDI contribute to less postoperative pain than EC? (2) is there any difference in side-effect occurrence between the methods? (3) does PMDI provide better functional recovery than EC? (4) is there any difference in inflammatory parameters between the methods?

HYPOTHESIS

PMDI would reduce postoperative pain and side effects, provide better functional recovery, and contribute to lower inflammation compared with EC.

MATERIALS AND METHODS

This single-center, randomized controlled trial was conducted from 2017 to 2019 and enrolled 55 patients randomly allocated into two groups (28 patients: PMDI, 27 patients: EC). The primary outcome was evaluated using the pain visual analogue scale (VAS). The secondary outcomes were narcotic consumption, side effects, hip range of motion (ROM), ratio of patients performing the straight leg raise (SLR) on postoperative day (POD) 1, the day the patient started using a walker and cane, and inflammatory parameters (white blood cell [WBC], and C-reactive protein [CRP]). Paired t-tests and Fisher's exact test were used for comparisons.

RESULTS

There were no significant differences in the pain VAS scores between groups. The EC group experienced significantly more side effects than the PMDI group (p<0.01). ROM of the PMDI group on POD 3 was significantly better than the EC group (p<0.05). Furthermore, more patients in the PMDI group could perform SLR than those in the EC group on POD 1 (p=0.01). On POD 1, the WBC count was significantly higher (p<0.01) in the PMDI group, whereas CRP levels were significantly lower in the PMDI group (p<0.05) and remained lower than the EC group on POD 3 (p<0.01).

DISCUSSION

The patients in the PMDI and EC groups had comparable postoperative pain. Those in the PMDI group had lower side effects. Functional recovery was comparable between the patients in the PMDI and EC groups. Compared to the EC group, the PMDI group had higher WBC count and lower CRP levels.

LEVEL OF EVIDENCE

I; Prospective randomized controlled trial.

A nomogram to predict the risk of prolonged length of stay following primary total hip arthroplasty with an enhanced recovery after surgery program

BACKGROUND

The aim of this study was to identify the risk factors associated with prolonged length of stay (LOS) in patients undergoing primary total hip arthroplasty (THA) managed with an enhanced recovery after surgery (ERAS) program and develop a prediction model for improving the perioperative management of THA.

METHODS

In this single-center retrospective study, patients who underwent primary THA in accordance with ERAS from May 2018 to December 2019 were enrolled in this study. The primary outcome was prolonged LOS (> 48 h) beyond the first postoperative day. We collected the clinical patient's clinical characteristics, surgery-related parameters, and laboratory tests. A logistic regression analysis explored the independent risk factors for prolonged LOS. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model to predict the risk of prolonged LOS following primary THA with an ERAS program. Evaluation indicators of the prediction model, including the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis, were reported to assess the performance of the prediction model. The bootstrap method was conducted to validate the performance of the designed nomogram.

RESULTS

A total of 392 patients were included in the study, of whom 189 (48.21%) had prolonged LOS. The logistics regression analysis demonstrated that age, sex, hip deformities, intraoperative blood loss, operation time, postoperative Day 1 (POD) hemoglobin (Hb), POD albumin (ALB), and POD interleukin-6 (IL-6) were independent risk factors for prolonged LOS. The C-index was 0.863 (95% CI 0.808 to 0.918) and 0.845 in the bootstrapping validation, respectively. According to the results of the calibration, ROC curve, and decision curve analyses, we found that the nomogram showed satisfactory performance for prolonged LOS in this study.

CONCLUSIONS

We explored the risk factors for prolonged LOS following primary THA with an ERAS program and developed a prediction model. The designed nomogram was expected to be a precise and personalized tool for predicting the risk and prognosis for prolonged LOS following primary THA with an ERAS program.

Safety and Feasibility of Video-Assisted Thoracoscopic Day Surgery and Inpatient Surgery in Patients With Non-small Cell Lung Cancer: A Single-Center Retrospective Cohort Study

Background and Objective: This study was undertaken to evaluate how safe and viable the use of video-assisted thoracoscopic day surgery (VATDS) is for individuals diagnosed with early-stage non-small cell lung cancer (NSCLC).

Methods: Data obtained from the selected patients with NSCLC who underwent video-assisted thoracoscopic surgery (VATS) in the same medical group were analyzed and a single-center, propensity-matched cohort study was performed. In total, 353 individuals were included after propensity score matching (PSM) with 136 individuals in the day surgery group (DSG) and 217 individuals in the inpatient surgery group (ISG).

Results: The 24-h discharge rate in the DSG was 93.38% (127/136). With respect to the postoperative complications (PPCs), no difference between the two groups was found (DSG vs. ISG: 11.76 vs. 11.52%, p = 0.933). In the DSG, a shorter length of stay (LOS) after surgery (1.47 ± 1.09 vs. 2.72 ± 1.28 days, p < 0.001) and reduced drainage time (8.45 ± 3.35 vs. 24.11 ± 5.23 h, p < 0.001) were found, while the drainage volume per hour (mL/h) was not notably divergent between the relevant groups (p = 0.312). No difference was observed in the cost of equipment and materials between the two groups (p = 0.333). However, the average hospital cost and drug cost of the DSG were significantly lower than those of the ISG (p < 0.001).

Conclusion: The study indicated that the implementation of VATDS showed no difference in PPCs, but resulted in shorter in-hospital stays, shorter drainage times, and lower hospital costs than inpatient surgery. These results indicate the safety and feasibility of VATDS for a group of highly selected patients with early-stage NSCLC.

Comparing ERAS-outpatient versus standard-inpatient hip and knee replacements: a mixed methods study exploring the experience of patients who underwent both

BACKGROUND

Optimizing patients' total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs.

METHODS

We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients' characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together.

RESULTS

The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients' THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36-0.66], p-value < 0.01).

CONCLUSION

Whatever the perioperative program, the key to improving patients' THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients' experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients' THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients

BACKGROUND

Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients.

METHODS

167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m²) and severely diseased patients (ASA≥3).

RESULTS

TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12).

CONCLUSION

Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.

Two types of anaesthesia and length of hospital stay in patients undergoing unilateral total knee arthroplasty (TKA): a secondary analysis based on a single-centre retrospective cohort study in Singapore

BACKGROUND

Evidence regarding the relationship between the type of anaesthesia and length of hospital stay is controversial. Therefore, the objective of this research was to investigate whether the type of anaesthesia was independently related to the length of hospital stay in patients undergoing unilateral total knee arthroplasty (TKA) after adjusting for other covariates.

METHODS

The present study was a cohort study. A total of 2622 participants underwent total knee arthroplasty (TKA) at a hospital in Singapore from 2013 to 1-1 to 2014-6-30. The target independent variable and the dependent variable were two types of anaesthesia and length of hospital stay, respectively. The covariates included age, BMI, hemoglobin (Hb), length of stay (LOS), duration of surgery, sex, ethnicity, American Society of Anesthesiologist (ASA) Status, smoking, obstructive sleep apnea (OSA), diabetes mellitus (DM), DM on insulin, ischemic heart disease (IHD), congestive cardiac failure (CCF), cerebrovascular accident (CVA), creatinine > 2 mg/dl, day of week of operation. Multivariate linear and logistic regression analyses were performed on the variables that might influence the choice of the two types of anaesthesia and the LOS. This association was then tested by subgroup analysis using hierarchical variables.

RESULTS

The average age of 2366 selected participants was 66.57 ± 8.23 years old, and approximately 24.18% of them were male. The average LOS of all enrolled patients was 5.37 ± 4.87 days, 5.92 ± 6.20 days for patients receiving general anaesthesia (GA) and 5.09 ± 3.98 days for patients receiving regional anaesthesia (RA), P < 0.05. The results of fully adjusted linear regression showed that GA lasted 0.93 days longer than RA (β = 0.93, 95% CI (0.54, 1.32)), P < 0.05. The results of fully adjusted logistic regression showed that LOS > 6 days was 45% higher for GA than for RA (OR = 1.45, 95% CI (1.15, 1.84)), P < 0.05. Through the subgroup analysis, the results were basically stable and reliable.

CONCLUSION

Our study showed that GA increased the length of stay during unilateral TKA compared with RA. This finding needs to be validated in future studies.

Participation in a Preoperative Patient Education Session Is a Significant Predictor of Better WOMAC Total Index Score and Higher EQ-5D-5L Health Status Index 1 Year After Total Knee and Hip Arthroplasties: A Retrospective Observational Study

OBJECTIVE

The aim of the study was to investigate whether patient-specific factors, preoperative patient-reported outcome measures, and participation in a preoperative patient education session significantly predict 1-yr Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) health status index of patients who underwent total hip or knee arthroplasties within an enhanced rehabilitation program.

DESIGN

This is a retrospective observational cohort study. The inclusion criteria were met by 676 (373 total hip arthroplasties and 303 total knee arthroplasties) patients. Two multiple regression models were carried out to estimate the contributions of nine potential predictors.

RESULTS

Younger age (P = 0.006), higher preoperative EQ-5D-5L index (P = 0.004), lower patient clinical complexity level (P = 0.001), lower preoperative WOMAC total score (P < 0.001), preoperative patient education session (P = 0.004), and submitting for total hip arthroplasty (P < 0.001) were significant predictors of better 1-yr WOMAC total score. Higher preoperative EQ-5D-5L index (P < 0.001), lower patient clinical complexity level classification (P < 0.001), lower preoperative WOMAC total score (P = 0.009), preoperative patient education session (P = 0.04), and submitting for total hip arthroplasty (P = 0.01) were significant predictors of higher 1-yr EQ-5D-5L health status index.

CONCLUSIONS

Better baseline patient-reported outcome measure scores, less comorbidities, younger age, submitting for total hip arthroplasty, and attending a preoperative patient education session were significant predictors of better WOMAC total scores and higher EQ-5D-5L health status index 1 yr after total hip or total knee arthroplasties.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis

Purpose

Enhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint.

Methods

We selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study.

Results

After PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey.

Conclusion

The introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.

Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study

BACKGROUND

Early mobilization after surgery is a cornerstone of the Enhanced Recovery After Surgery (ERAS) programs in total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our goal was to determine the time to mobilization after this surgery and the factors associated with early mobilization.

METHODS

This was a predefined substudy of the POWER.2 study, a prospective cohort study conducted in patients undergoing THA and TKA at 131 Spanish hospitals. The primary outcome was the time until mobilization after surgery as well as determining those perioperative factors associated with early mobilization after surgery.

RESULTS

A total of 6093 patients were included. The median time to achieve mobilization after the end of the surgery was 24.áhours [16.Çô30]. 4,222 (69.3%) patients moved in .ëñ 24.áhours after surgery. Local anesthesia [OR.á=.á0.80 (95% confidence interval [CI]: 0.72.Çô0.90); p.á=.á0.001], surgery performed in a self-declared ERAS center [OR = 0.57 (95% CI: 0.55.Çô0.60); p.á<.á0.001], mean adherence to ERAS items [OR.á=.á0.93 (95% CI: 0.92.Çô0.93); p.á<.á0.001], and preoperative hemoglobin [OR.á=.á0.97 (95% CI: 0.96.Çô0.98); p.á<.á0.001] were associated with shorter time to mobilization.

CONCLUSIONS

Most THA and TKA patients mobilize in the first postoperative day, early time to mobilization was associated with the compliance with ERAS protocols, preoperative hemoglobin, and local anesthesia, and with the absence of a urinary catheter, surgical drains, epidural analgesia, and postoperative complications. The perioperative elements that are associated with early mobilization are mostly modifiable, so there is room for improvement.

Postoperative thromboprophylaxis does not reduce the incidence of thromboembolic events after ACL reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) reconstructive surgery is one of the most common ligament-related surgeries performed in France. The French Society of Anesthesia & Intensive Care Medicine (SFAR) recommends the systematic use of low-molecular weight heparin postoperatively to prevent venous thromboembolisms (VTE). However, these recommendations differ from one country to another; several national societies do not recommend them. To specify the benefits of such a treatment, we did a retrospective case-control study to evaluate the incidence of symptomatic VTE after ACL reconstruction. Hypothesis We hypothesized that the rate of symptomatic VTE would be the same, whether a course of postoperative anticoagulants is prescribed or not.

METHODS

This was a retrospective, multicenter, multi-surgeon study. Of the four participating surgeons, two never prescribed thromboprophylaxis after surgery while the other two always prescribed a 10-day course of low-molecular weight heparin. All patients who underwent primary ACL reconstruction using an autologous graft between the 1st of January 2019 and the 15th of February 2020 were included. The 535 patients who had undergone ACL reconstruction were divided into two groups: (Group 1) 279 patients in the group without anticoagulants; 96% received a four-strand semi-tendinosus graft (ST4) and 4% received a quadriceps tendon (QT) graft; the mean age of these patients was 30 years (14-58); 41% of them were women and 22% of them were smokers; the mean body mass index was 24.4 (18-37); the mean tourniquet time was 37minutes. (Group 2) 256 patients in the group with anticoagulants; 81% received a semi-tendinosus/gracilis graft, 15% received a ST4 and 4% a QT; the mean age of these patients was 29 years (14-60); 38% of them were women and 21% of them were smokers; the mean body mass index was 25.0 (18-38); the mean tourniquet time was 34minutes. The two groups were comparable in all respects except for the type of graft used. All patients were contacted at a minimum interval of 3 months after their surgery, by telephone. Doppler ultrasonography was done solely when a VTE was suspected.

RESULTS

In the group without anticoagulants, 249 of 279 patients were contacted, while in the group with anticoagulants, 221 of 256 were contacted. The two groups were comparable in terms of age, gender ratio, tourniquet time, body mass index and proportion of smokers. Two cases of deep vein thrombosis (all in the calf region) were found in each group with no associated pulmonary embolism. There was no difference between groups in the VTE rate.

DISCUSSION

Our hypothesis was confirmed since the incidence of symptomatic VTE was the same whether postoperative anticoagulants were prescribed or not. The incidence of symptomatic VTE after ACL reconstruction was identical whether thromboprophylaxis was used or not. This casts doubt on the need for postoperative thromboprophylaxis, especially in younger patients who do not have risk factors, and brings into question whether the recommendations in France should be changed.

LEVEL OF EVIDENCE

III (retrospective case-control study).

Duloxetine reduces pain after Total hip arthroplasty: a prospective, randomized controlled study

BACKGROUND

Previous studies have demonstrated the efficacy of duloxetine in reducing postoperative pain and opioid consumption. However, the effect of duloxetine on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of oral duloxetine in THA.

METHODS

We enrolled 96 patients in this randomized controlled trial. These patients were randomized (1,1) to either the duloxetine group or the placebo group and received daily doses of 60 mg duloxetine or placebo, respectively, from 2 d pre-operation to 14 d after surgery. The primary outcome was pain severity upon movement measured by a visual analogue scale (VAS). The secondary outcomes included VAS scores for resting pain, morphine consumption, Harris Hip Score, patient satisfaction at discharge, length of postoperative hospital stay, and adverse events.

RESULTS

Patients in the duloxetine group had significantly lower pain severity scores upon movement within 3 postoperative weeks (p < 0.05) while none of the differences met the minimum clinically important difference (MCID). Moreover, patients in the duloxetine group performed better in terms of resting pain (in 3 weeks after surgery), morphine requirements, and satisfaction level at discharge (all p < 0.05). There was no difference between groups in the prevalence of adverse events.

CONCLUSIONS

Although it did not result in a clinically meaning reduction in pain after total hip arthroplasty, perioperative administration of 60 mg of duloxetine daily significantly alleviated pain in the postoperative 3 weeks and morphine requirements during the postoperative 48 h. Therefore, duloxetine still shows promise in optimizing the multimodal pain-management protocols in total hip arthroplasty.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000033606 , 06/06/2020.

Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital

INTRODUCTION

In total knee replacement (TKR) surgeries, "fast-track" or enhanced recovery after surgery (ERAS) programs are being developed, but their impact on care pathway quality and safety has not been fully explored in the French literature. The present study aimed to compare results in TKR between fast-track and conventional pathways, addressing the following questions: (1) Are 90-day rates of complications, readmission and surgical revision higher with fast-track? (2) Is mean length of stay (LoS) shorter with fast-track? (3) Are postoperative pain and clinical results improved by fast-track? And, (4) are patients and care staff satisfied with these new programs?

HYPOTHESIS

Implementing fast-track for TKR in a university hospital center is beneficial for the patient and does not impair the quality and safety of care.

PATIENTS AND METHOD

A case-control study was performed using a retrospective analysis of prospectively collected data. A fast-track program was implemented for TKR by modifying the care pathway. This involved instituting a therapeutic education consultation, optimizing blood sparing, modifying surgical practices, and hastening early mobilization thus actively involving patients in their own management. Between January 2017 and January 2019, 216 patients with a mean age of 69.23±7.80years and mean BMI of 30.15±4.79kg/m² were included in the fast-track group, with 335 matched patients included in the conventional group.

RESULTS

At 90days, there were no significant inter-group differences in rates of infection (fast-track=1.39%, conventional=0.90%; p=0.34), readmission (fast-track=3.24%, conventional=3.58%; p=0.49), or surgical revision (fast-track=2.78%, conventional=2.69%; p=0.298). The visual analog scale (VAS) pain rating was 1.56±1.36 in the fast-track group versus 5±2.41 in the conventional group; p<0.001. LoS was 3.17±1.59days in fast-track versus 7.25±1.85days in the conventional group; p<0.001. Ninety-five percent of patients and 96% of care staff were satisfied with the fast-track program.

DISCUSSION

Fast-track implementation ensured quality and safety of care; it did not increase the rate of complications in primary TKR. Mean length of stay was drastically reduced. Both patients and care staff were very satisfied with these new procedures.

LEVEL OF EVIDENCE

III; case-control study.

Combining enhanced recovery and short-stay protocols for hip and knee joint replacements: the ideal solution

Pressure to reduce health care costs, limited hospital bed availability as well as improvements in surgical techniques and perioperative care motivated many health care centres to implement short-stay protocols for patients undergoing hip or knee arthroplasty. To improve patient outcomes and maintain care safety, we strongly believe the best way to implement a successful outpatient program would be to embrace the principles of Enhanced Recovery After Surgery (ERAS), and to improve patient recovery to a level such that the patient could leave the hospital sooner. Enhanced Recovery Canada and the Canadian Patient Safety Institute support the development of ERAS pathways for orthopedic procedures. The goal is to provide patients, health care providers and leaders with helpful tools and resources to effectively implement and sustain ERAS protocols. Reducing the rate of adverse events while reducing the length of hospital stays to less than 24 hours is a winning situation for everyone.

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

BACKGROUND

There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA.

METHODS

Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed.

RESULTS

In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases.

CONCLUSION

Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

Application of enhanced recovery after surgery in total knee arthroplasty in patients with haemophilia A: A pilot study

Aim

To identify the effect of enhanced recovery after surgery (ERAS) and rapid rehabilitation concepts on the outcomes of patients with haemophilia A undergoing total knee arthroplasty.

Design

Randomized controlled trial.

Methods

The primary endpoint was postoperative hospital stay. The secondary endpoints were pain scores, joint function scores, haemoglobin levels at 3 and 7 days after surgery and satisfaction with hospitalization.

Results

Thirty-two patients were enrolled. Compared with the routine nursing group, the ERAS group showed shorter postoperative hospital stay (14.2 SD 0.8 vs. 16.6 ± 1.3 days, p < .001), smaller amounts of blood transfusion (924 SD 317 vs. 1,263 SD 449 ml, p = .020) and coagulation factors (37,325 SD 5,996 vs. 48,475 SD 8,019 U, p < .001), lower pain scores at 3 (3.3 SD 0.7 vs. 4.3 SD 0.7, p = .002) and 7 (2.3 SD 0.7 vs. 2.8 ± 0.5, p = .015) days, lower hospital for special surgery knee scores at 3 (59.9 SD 7.8 vs. 53.6 SD 5.9, p = .016) and 7 (77.9 SD 6.9 vs. 71.1 ± 7.1, p = .009) days and higher satisfaction with hospitalization (94.3 SD 1.4 vs. 92.7 SD 1.6, p = .004).

Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases

STUDY OBJECTIVES

To investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type.

DESIGN

Retrospective analysis.

SETTING

Operating room.

PATIENTS

349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%).

INTERVENTIONS

No intervention.

MEASUREMENTS

The effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year.

MAIN RESULTS

The OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31-1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased.

CONCLUSIONS

The OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program

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.

Time Trends and Risk Factors for 30-Day Adverse Events in Black Patients Undergoing Primary Total Knee Arthroplasty

BACKGROUND

Increased adverse events (AEs) have been reported among black patients undergoing joint arthroplasty, but little is known about their persistence and risk factors. The purpose of this study is (1) to examine recent annual trends in 30-day outcomes after total knee arthroplasty (TKA) and (2) to develop a preoperative risk stratification model in this racial minority.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried for all black/African American patients who underwent primary TKA between 2011 and 2017. Time trends in demographic variables, comorbid conditions, perioperative characteristics, length of stay (LOS), and 30-day readmissions, reoperations, medical complications, surgical complications, and mortality were assessed. Multivariate logistic regression analyses were performed to identify independent risk factors for development of 30-day AEs.

RESULTS

In total, 19,496 black patients were analyzed. Between 2011 and 2017, there have been improved comorbidity profiles (P < .02), decreased LOS (P < .001), and lower rates of AEs (P < .001). Significant risk factors for developing AEs were male gender, tobacco smoking, American Society of Anesthesiologists score >2, dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, metastatic cancer, dyspnea, chronic kidney disease, bilateral TKA, and operative time >100 minutes.

CONCLUSION

There have been significant improvements in the annual trends of LOS and 30-day outcomes among black patients undergoing primary TKA in recent years. A predictive model for 30-day AEs was developed to help guide risk stratification and optimization of modifiable factors, namely anemia, tobacco smoking, bilateral surgery, and operative time.

Enhanced recovery after surgery (ERAS) program for elderly patients with short-level lumbar fusion

Background

Degenerative disorders of the lumbar spine decrease the mobility and quality of life of elderly patients. Lumbar fusion surgery is the primary method of treating degenerative lumbar spine disorders; however, the surgical stress response associated with major surgery has been linked to pathophysiological changes in the elderly, resulting in undesirable postoperative morbidity, complications, pain, fatigue, and extended convalescence. In the present study, we aimed to determine whether enhanced recovery after surgery significantly improved satisfaction and outcomes in elderly patients (> 65 years old) with short-level lumbar fusion.

Methods

The study enrolled lumbar disc herniation or lumbar spinal stenosis patients if they were over the age of 65 years old underwent lumbar fusion at one or two levels. Data including demographic, comorbidity, and surgical information were collected from electronic medical records. Enhanced recovery after surgery interventions was categorized as preoperative, intraoperative, and postoperative. We also evaluated primary outcome, surgical complication, length of stay, postoperative pain scores, and 30-day readmission rates.

Results

A total of 192 patients were included, 96 in the enhanced recovery after surgery group and 96 case-matched patients in the non- enhanced recovery after surgery group. There were no statistically significant intergroup differences in regards to demographics, comorbidities, American Society of Anaesthesiologists grade, or the number of fusion levels. There were also no differences between mean surgery time of intraoperative blood loss between the enhanced recovery after surgery and non- enhanced recovery after surgery groups. In addition, the mean preoperative Japanese Orthopaedic Association score, visual analog score for the back and legs, and Oswestry Disability Index score were not significantly different between the two groups. Overall, enhanced recovery after surgery pathway compliance was 92.1%. There were no significant differences in the number of complications or the mortality rates between the enhanced recovery after surgery and non-enhanced recovery after surgery groups. Furthermore, the mean postoperative Japanese Orthopaedic Association score, Visual analog score for the back and legs, Oswestry Disability Index score, and readmission rates score revealed no significant differences between the groups at 30-day follow-up point. However, we observed a statistically significant decrease in length of stay in the enhanced recovery after surgery group (12.30 ± 3.03 of enhanced recovery after surgery group versus 15.50 ± 1.88 in non- enhanced recovery after surgery group, p = 0). Multivariable linear regression showed that comorbidities (p = 0.023) and implementation of enhanced recovery after surgery program (p = 0.002) were correlated with prolonged length of stay. Multivariable logistic regression showed that no characteristics were associated with complications.

Conclusions

This report describes the first enhanced recovery after surgery protocol used in elderly patients after short-level lumbar fusion surgery. Our enhanced recovery after surgery program is safe and could help decrease length of stay in elderly patients with short-level lumbar fusion.