Complication Rates Following Total Ankle Arthroplasty in Inpatient versus Outpatient Populations: A Systematic Review & Meta-Analysis

Unplanned Postoperative Emergency Department Visits After Upper Extremity Fracture Surgery

OBJECTIVES

This study aimed to determine whether outpatient upper extremity fracture surgery was associated with increased postoperative emergency department (ED) visits and identify related risk factors.

METHODS

DESIGN

Retrospective cohort.

SETTING

This multicenter study was conducted within a single academic institution, encompassing two Level 1, two Level 2, and one Level 3 trauma centers.

PATIENT SELECTION CRITERIA

All patients >18 years of age who underwent upper extremity fracture surgery from 2015 to 2021 were included.

OUTCOME MEASURES AND COMPARISONS

Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a P < 0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90 days.

RESULTS

A total of 6315 patients with an average age of 51 ± 19 years were identified of whom 52% were women and 65% had outpatient surgery. Postoperatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increased to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (odds ratio [OR]: 1.5, P = 0.030), tobacco use (OR: 2.1, P < 0.001), higher Elixhauser comorbidity scores (OR: 1.2, P < 0.001), non-White race (OR: 1.9, P < 0.001), elbow fractures (OR: 1.8, P = 0.016), and hand fractures (OR: 1.6, P = 0.046) were associated with 30-day ED visits.

CONCLUSIONS

Outpatient surgery was associated with increased rate of 30-day ED visits. Patients who smoke, had increased number of comorbidities, or were non-White presented to the ED more frequently.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outpatient surgical fixation of complicated calcaneal fractures pose no excess risk for 30-day complications

The purpose of this study was to identify if complicated open reduction internal fixation (ORIF) of calcaneal fractures (i.e. requiring bone graft) performed in the outpatient setting poses an excess risk for 30-day complications compared to inpatient procedures. We included patients who underwent ORIF of the calcaneus involving the use of bone graft utilizing CPT code 28420 from the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) between 2014 and 2019. Postoperative complications, demographic data, patient characteristics, and operative factors were compared between groups. T-tests were performed to assess univariate associations between outpatient status and surgical/patient demographics for continuous variables while chi-squared tests were performed to evaluate categorical variables. A total of 113 patients were included, experiencing a 2.6% short term complication rate (3/113). All 3 complications occurred in the outpatient setting. 51.3% of surgeries were performed on an inpatient basis. In the univariate analysis, there were no statistically significant differences between inpatient and outpatient 30-day postoperative complication rates. Although more complications were recognized in the outpatient population, this did not reach statistical significance and suggests that complicated calcaneal ORIF procedures involving bone graft may be performed in the outpatient setting without posing an excess risk.

Complications, Readmissions, and Reoperations in Outpatient vs Inpatient Total Ankle Arthroplasty: A Systematic Review and Meta-analysis

Background

Total ankle arthroplasty (TAA) has primarily been performed in the inpatient setting. However, with the advent of fast-tracked joint arthroplasty protocols, TAA has slowly been shifting to the outpatient setting. Therefore, this systematic review aims to evaluate outcomes of outpatient TAA and compare them to inpatient TAA.

Methods

A literature search was performed on October 23, 2023, in the PubMed, Embase, and CENTRAL databases using the PRISMA guidelines. Studies were included if they reported on outcomes of outpatient TAA or compared outcomes between outpatient and inpatient TAA. Pooled odds ratios (ORs) and mean differences were calculated using a random effects model. Quality assessment was performed using the MINORS criteria.

Results

12 studies were included, with 4 outpatient-only and 8 outpatient-inpatient comparative studies. Patients in the outpatient group were relatively younger, had a lower body mass index, and had fewer comorbidities relative to the inpatient group. For outpatient vs inpatient TAA, the pooled complication rate was 2.6% vs 3.6%, readmission rate was 2.5% vs 4%, and reoperation rate was 3.6% vs 5.5%. We found significantly lower odds of complications (OR = 0.47, CI: 0.26-0.85; P = .01), readmissions (OR = 0.63, CI: 0.54-0.74; P < .00001), and reoperations (OR = 0.66, CI: 0.46-0.95; P = .03) in the outpatient vs inpatient group.

Conclusion

Although this analysis is limited by the dominance of data included from a single study, we found that outpatient TAA was generally performed on lower-risk patients and was associated with lower rates of complications, readmissions, and reoperations compared with inpatient TAA.

Complications in Total Ankle Replacement

The debate between ankle arthrodesis and total ankle replacement for patients with end-stage arthritis of the ankle joint is an ongoing topic in orthopedic surgery. Ankle arthrodesis, or fusion, has been the traditional treatment for ankle arthritis. It involves fusing the bones of the ankle joint together, eliminating the joint and creating a solid bony union. Arthrodesis is effective in reducing pain in the ankle, but it results in a loss of ankle motion. This can increase the load on adjacent joints, such as the subtalar joint, which may lead to accelerated degeneration and arthritis in those joints over time.

Outpatient Total Ankle Arthroplasty (TAA) as a Rising Alternative to Inpatient TAA: A Database Analysis

BACKGROUND

There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the benefit of decreased health care expenses and improved patient satisfaction. The purpose of our study was to compare readmissions, arthroplasty failures, infections, and annual trends between outpatient and inpatient TAA using a large publicly available for-fee database.

METHODS

The PearlDiver Database was queried to identify outpatient and inpatient TAA-associated claims for several payer types from January 2010 to October 2021. Preoperative patient characteristics and annual trends were compared for inpatient and outpatient TAA. International Classification of Diseases, Ninth and Tenth Revision, diagnosis codes were used to identify infections and arthroplasty failures. Complications rates were compared after matching patients by age, gender, and the following comorbidities: diabetes, smoking, congestive heart failure (CHF), hypertension (HTN), obesity, and chronic kidney disease (CKD).

RESULTS

A total of 12 274 patients were included in the final exact-matched analysis for complications, with 6137 patients in each group. Outpatients had a significantly lower rate of readmission within 90 days (2.6% vs 4.0%, P < .001), arthroplasty failure (4.1% vs 6.9%, P < .001), and infection (2.4% vs 3.1%, P = .015). Among database enrollees, outpatient TAA has risen in proportion to inpatient TAA from 2019 to 2021.

CONCLUSION

Outpatient TAA had lower rates of risk-adjusted readmission, arthroplasty failure, and infection compared to inpatient TAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative database study.

Five-Factor Modified Frailty Index as a Predictor of Complications Following Total Ankle Arthroplasty

INTRODUCTION

Ankle arthritis adversely affects patients' function and quality of life. Treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA). A 5-item modified frailty index (mFI-5) has predicted adverse outcomes following multiple orthopaedic procedures; this study evaluated its suitability as a risk-stratification tool in patients undergoing TAA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for patients undergoing TAA between 2011 and 2017. Bivariate and multivariate statistical analyses were performed to investigate frailty as a possible predictor of postoperative complications.

RESULTS

In total, 1035 patients were identified. When comparing patients with an mFI-5 score of 0 versus ≥2, overall complication rates significantly increased from 5.24% to 19.38%, 30-day readmission rate increased from 0.24% to 3.1%, adverse discharge rate increased from 3.81% to 15.5%, and wound complications increased from 0.24% to 1.55%. After multivariate analysis, mFI-5 score remained significantly associated with patients' risk of developing any complication (P = .03) and 30-day readmission rate (P = .005).

CONCLUSIONS

Frailty is associated with adverse outcomes following TAA. The mFI-5 can help identify patients who are at an elevated risk of sustaining a complication, allowing for improved decision-making and perioperative care when considering TAA.

LEVELS OF EVIDENCE

III, Prognostic.

Innovative models of healthcare delivery: an umbrella review of reviews

OBJECTIVE

To undertake a synthesis of evidence-based research for seven innovative models of care to inform the development of new hospitals.

DESIGN

Umbrella review.

SETTING

Interventions delivered inside and outside of acute care settings.

PARTICIPANTS

Children and adults with one or more identified acute or chronic health conditions.

DATA SOURCES

PsycINFO, Ovid MEDLINE and CINAHL.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical indicators and mortality, healthcare utilisation, quality of life, self-management and self-care and patient knowledge.

RESULTS

A total of 66 reviews were included, synthesising evidence from 1272 primary studies across the 7 models of care. Virtual care was the most common model studied, addressed by 47 (73%) of the reviews. Common outcomes evaluated across reviews were clinical indicators and mortality, healthcare utilisation, self-care and self-management, patient knowledge, quality of life and cost-effectiveness. The findings indicate that the innovative models of healthcare we identified in this review may be effective in managing patients with a range of acute and chronic conditions. Most of the included reviews reported evidence of comparable or improved care.

CONCLUSIONS

A consideration of local infrastructure and individual patient characteristics, such as health literacy, may be critical in determining the suitability of models of care for patients and their implementation in local health systems.

TRIAL REGISTRATION NUMBER

10.17605/OSF.IO/PS6ZU.

Systemic medical complications following total ankle arthroplasty: A review of the evidence

BACKGROUND

Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent.

METHODS

We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA.

RESULTS

The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration.

CONCLUSIONS

When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.