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Tong EYH, Sattar M, Rankin IA, Ashcroft GP. Increased Duration of Total Hip and Total Knee Arthroplasty Surgery Increases the Risk of Post-Operative Urinary Retention: A Retrospective Cohort Study. J Clin Med 2024; 13:3102. [PMID: 38892812 PMCID: PMC11172424 DOI: 10.3390/jcm13113102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Post-operative urinary retention (POUR) is a common complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Spinal anaesthetic has been associated with an increased risk of POUR, whilst other risk factors remain unclear. This study aims to identify modifiable and non-modifiable risk factors of POUR for THA and TKA patients. Methods: A single-centre retrospective cohort study of patients admitted to our hospital over the course of 6 weeks from September to October 2021 for a THA or TKA. All patients who underwent elective THA/TKA were included, and trauma cases were excluded. Results: Ninety-two consecutive patients were included in this study. The overall rate of POUR was 17%. A shorter operative duration resulted in a reduced risk of POUR (median duration of non-retention patients, 88 min vs. 100 min POUR patients; odds ratio, 0.97; 95% CI, 0.95-0.99, p = 0.018). The median bladder volume of patients with urinary retention at the point of diagnosis was 614 mL (range, 298-999 mL). The arthroplasty type, anaesthetic technique, pre-operative morphine use, body mass index, age, cardiovascular disease, and renal disease were found to have no significant association with POUR. Conclusions: A reduced operative time of arthroplasty surgery is associated with a decreased risk of POUR. Patients with a prolonged operative time should have an increased frequency of micturition monitoring in the immediate post-operative period.
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Affiliation(s)
- Edwin Yuen Hao Tong
- Trauma and Orthopaedics, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK; (M.S.); (G.P.A.)
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Evans WS, Ziemba-Davis M, Buller LT, Meneghini RM. Efficacy and Safety of Catheter Interventions for Postoperative Urinary Retention After Primary Hip and Knee Total Joint Arthroplasty. J Am Acad Orthop Surg 2024:00124635-990000000-00997. [PMID: 38781355 DOI: 10.5435/jaaos-d-23-01211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Postoperative urinary retention (POUR) is a common barrier to rapid-discharge hip and knee total joint arthroplasty (TJA). We evaluated the efficacy and safety of catheterization intervention methods for POUR before and after discharge. METHODS A total of 1,659 primary TJAs were retrospectively reviewed. POUR resolutions before and after discharge were evaluated relative to catheterization type and other covariates. Complications before and within 90 days of discharge were quantified. A total of 113 POUR cases comprised the analysis sample of 76 hips and 37 knees in 51 women and 62 men with an average age and body mass index of 68.6 (range 22 to 92) years and 31.7 (range 16 to 49) kg/m2. RESULTS POUR resolved before discharge for 82.3% (93/113) of patients, with equivalent resolution rates for intermittent catheterization alone (84.2%, 32/38) compared with indwelling catheterization with or without intermittent catheterization (82.6%, 57/69, P < 0.999), equivalent time to resolution (P = 0.319), and no difference in complication rates (P = 0.999). Complication rates within 90 days of discharge were higher for patients treated with indwelling catheters before discharge (P = 0.049). Resolution before discharge was more likely with increasing body mass index (P = 0.026) and less likely for patients with a history of urinary retention (P = 0.033). 60 percent (12/20) of patients with unresolved POUR were discharged with self-intermittent catheterization and 40% (8/20) with indwelling catheters, with no differences in efficacy and safety based on the catheterization type (P = 0.109). DISCUSSION Before discharge, we observed equivalent resolution rates and equivalent time to resolution for indwelling and intermittent catheterization alone without compromising patient safety. Intermittent catheterization is favored, however, because in situ catheter exposure is dramatically reduced and postdischarge complication rates are lower. Additional research is needed to develop evidence-based POUR guidelines for outpatient TJA.
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Affiliation(s)
- William S Evans
- From the Department of Graduate Medical Education, Indiana University School of Medicine, Indianapolis, IN (Evans), Indiana University Health Multispecialty Musculoskeletal Center, Carmel, IN (Ziemba-Davis), Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN (Buller, and Meneghini)
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Risk factors for postoperative urinary retention following elective spine surgery: a meta-analysis. Spine J 2021; 21:1802-1811. [PMID: 34015508 DOI: 10.1016/j.spinee.2021.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/18/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Limited studies have investigated risk factors for postoperative urinary retention (POUR) following elective spine surgery. Furthermore, some discrepancies have been found in the results of existing observational studies. PURPOSE This study aimed to review the available literature on risk factors associated with POUR following elective spine surgery. STUDY DESIGN A systematic review with meta-analysis was performed. PATIENT SAMPLE A total of 31,251 patients (POUR=2,858, no POUR=28,393) were included in the meta-analysis. OUTCOME MEASURES Demographics, type of elective spine surgery, country, definition of POUR, and potential risk factors for POUR were evaluated. METHODS The Cochrane Library, Embase, and Medline electronic databases were searched to identify relevant studies. Binary outcomes were reported as odds ratio (OR). Weighted mean differences (WMD) or standardized mean differences (SMD), with 95% confidence intervals (CI), were used for meta-analysis of continuous outcomes. RESULTS Eleven studies (2 prospective and 9 retrospective) were included in the analysis. Patients with POUR were older than those without POUR (WMD, 7.13; 95% CI, 4.50-9.76). Male patients were found to have an increased risk of POUR (OR, 1.31; 95% CI, 1.04-1.64). The following variables were also identified as significant risk factors for POUR: benign prostatic hyperplasia (BPH; OR, 3.79; 95% CI, 1.89-7.62), diabetes mellitus (DM; OR, 1.50; 95% CI, 1.17-1.93), and previous urinary tract infection (UTI; OR, 1.70; 95% CI, 1.28-2.24). Moreover, longer operative time (WMD, 19.88; 95% CI, 5.01-34.75) and increased intraoperative fluid support (SMD, 0.37; 95% CI, 0.23-0.52) were observed in patients with POUR. In contrast, spine surgical procedures involving fewer levels (OR, 0.75; 95% CI, 0.65-0.86), and ambulation on the same day as surgery (OR, 0.65; 95% CI, 0.52-0.81) were associated with a decreased risk of POUR. CONCLUSIONS Based on our meta-analysis, older age, male gender, BPH, DM, and a history of UTI are risk factors for POUR following elective spine surgery. We also found that longer operative time and increased intravenous fluid support would increase the risk of POUR. Additionally, multi-level spine surgery may have a negative effect on postoperative voiding.
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Key Words
- CAD, coronary artery disease
- CI, confidence Interval
- DM, diabetes mellitus
- Elective surgery
- IAP, intra-abdominal pressure
- IQR, interquartile range
- Meta-analysis Abbreviations: BPH, benign prostatic hyperplasia
- OR, odds ratio
- POUR, postoperative urinary retention
- PVR, post-void residual
- Postoperative urinary retention
- Risk factor
- SD, standard deviation
- SMD, standardized mean differences
- Spine surgery
- Systematic review
- UTI, urinary tract infection
- WMD, weighted mean difference
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Wei B, Tang C, Li X, Lin R, Han L, Zheng S, Xu Y, Yao Q, Wang L. Enhanced recovery after surgery protocols in total knee arthroplasty via midvastus approach: a randomized controlled trial. BMC Musculoskelet Disord 2021; 22:856. [PMID: 34625057 PMCID: PMC8501665 DOI: 10.1186/s12891-021-04731-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/22/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols were rapidly adopted in many surgeries such as fast-track arthroplasty. The study aimed to investigate the impact of ERAS protocols on the clinical effect of total knee arthroplasty (TKA) via the midvastus approach. METHODS A total of 69 patients who underwent primary unilateral TKA via the midvastus approach from October 2018 to June 2019 were enrolled and randomly divided into two groups: ERAS group and Control group. The ERAS protocols were adopted for the ERAS group and consisted of pure juice drinking 2 h before the surgery, optimization of the preoperative anesthesia plan, phased use of tourniquets, and the use of tranexamic acid as well as a drug cocktail. The operative time, first postoperative walking time, first straight leg elevation time, postoperative hospitalization time, visual analogue scale score (VAS score), Hospital for Special Surgery score (HSS score), conventional Knee Society score (KSS), and knee range of motion (ROM) were used to assess the clinical effects in the two groups. All the included patients were followed up for 12 months. RESULTS There were no significant differences in the basic demographic information and operation time between the ERAS and Control groups (P > 0.05). The first postoperative walking time (2.11 ± 0.11 h) and first postoperative straight leg elevation time (6.14 ± 1.73 h) in the ERAS group were significantly earlier than those in the Control group (P < 0.001) and the postoperative hospitalization time was significantly shorter (3.11 ± 0.32 days). The postoperative mean VAS scores in both groups were significantly reduced compared with those before surgery (P < 0.001). The VAS scores for the ERAS group were significantly lower than those for the Control group at 1, 2, and 7 days after surgery (P < 0.001). The mean HSS scores, KSS, and knee ROM were significantly increased in both the ERAS and Control groups at 1, 3, 6, and 12 months after surgery (P < 0.001). In addition, the HSS scores, KSS, and knee ROM in the ERAS group were significantly higher than those in the Control group at 1 month after surgery (P < 0.001). CONCLUSIONS ERAS protocols improved the clinical effects of TKA via the midvastus approach, facilitating early out-of-bed activity and comfortable postoperative rehabilitation exercise, and further increasing patient satisfaction. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04873544 .
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Affiliation(s)
- Bo Wei
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Cheng Tang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Xuxiang Li
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Rongcai Lin
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Liu Han
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Suyang Zheng
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Yan Xu
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Qingqiang Yao
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Liming Wang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China. .,Digital Medicine Institute, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.
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Pivec R, Wickes CB, Austin MS. Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention. J Arthroplasty 2021; 36:1904-1907. [PMID: 33608180 DOI: 10.1016/j.arth.2021.01.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Post-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. METHODS All male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. RESULTS Two hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m2. The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69. CONCLUSION Urodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.
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Affiliation(s)
- Robert Pivec
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - C Baylor Wickes
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Shuai M, Li Y. Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25490. [PMID: 33847659 PMCID: PMC8052073 DOI: 10.1097/md.0000000000025490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 03/23/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to assess whether a urinary catheter is necessary for all patients in primary total knee arthroplasty (TKA). METHODS PubMed, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure were systematically searched for randomized controlled trials (RCTs). All RCTs were compared with receive either an indwelling urinary catheter or no urinary catheter in TKA. Primary outcomes were urinary retention and urinary tract infection. Secondary outcomes were the length of stay, duration of the surgery, and the first urination time. RESULTS A total of 6 RCTs involving 1334 patients were included in the meta-analysis. No significant difference between the 2 groups was found in urinary retention (P = .52), length of stay (P = .38), duration of the surgery (P = .55). However, patients with an indwelling catheter were associated with a higher risk of urinary tract infections and longer time for the first urination than patients without indwelling catheters (P = .009 and P = .004). CONCLUSION The available evidence indicates that patients without using the indwelling catheters could reduce urinary tract infections and the time for the first urination, without increase in the incidence of urinary retention in primary TKA. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Mingying Shuai
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yueping Li
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study. J Arthroplasty 2021; 36:837-844. [PMID: 33616066 DOI: 10.1016/j.arth.2020.09.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/16/2020] [Accepted: 09/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. METHODS This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. RESULTS The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030). CONCLUSION Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. LEVEL OF EVIDENCE Level III.
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Wang Y, Li G, Momin M, Ji B, Cao L, Aisikeerbayi A. Comparison of different local analgesia protocols in postoperative pain management after total knee arthroplasty. Braz J Anesthesiol 2021; 72:267-273. [PMID: 33814226 PMCID: PMC9373605 DOI: 10.1016/j.bjane.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives This study was to compare the effects of different local analgesia protocols on osteoarthritis patients undergoing total knee arthroplasty (TKA). Methods Medical records of 148 osteoarthritis patients who underwent unilateral TKA between October 2016 and October 2017 in our hospital were retrospectively analyzed. All these patients were divided into three groups according to the pain management protocol (morphine, morphine + cocktail [100 mg ropivacaine, 10 mg morphine, and 30 mL 0.9% sodium chloride solution containing 2 mL betamethasone (4 mg)], or cocktail). The postoperative visual analog scale (VAS) score, muscle strength, and complications were compared between the groups. Results At 6 and 12 hours post-operation, the VAS score in group C was significantly higher than that in group A or group B. In addition, the muscle (quadriceps femoris) strength score of group C (3.7 ± 2.8) was significantly higher than that in groups A and B at 6 and 12 hours post-operation. The VAS score and muscle strength score showed no significant differences among the three groups at 24 and 36 hours post-operation. The time of postoperative first void of group C was significantly shorter than that of groups A and B. Groups A or B had a significantly higher incidence of nausea and emesis compared with group C. The incidence of pruritus was higher in groups A or B than that in group C. Conclusion Epidural anesthesia combined with local analgesic cocktail injection is a preferable effective multimodal analgesia for TKA.
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Affiliation(s)
- Yang Wang
- The First Affiliated Hospital of Xinjiang Medical University, Department of Orthopedics, Urumqi, China
| | - Guoqing Li
- The First Affiliated Hospital of Xinjiang Medical University, Department of Orthopedics, Urumqi, China
| | - Muhtar Momin
- The First Affiliated Hospital of Xinjiang Medical University, Department of Orthopedics, Urumqi, China
| | - Baochao Ji
- The First Affiliated Hospital of Xinjiang Medical University, Department of Orthopedics, Urumqi, China
| | - Li Cao
- The First Affiliated Hospital of Xinjiang Medical University, Department of Orthopedics, Urumqi, China.
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Karani R, Mahdy A, Asghar F. Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery. JBJS Rev 2020; 8:e18.00040. [PMID: 32759614 DOI: 10.2106/jbjs.rvw.18.00040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Postoperative urinary retention (POUR) may result from orthopaedic procedures and potentially lead to bacteremia and chronic voiding difficulties.
Risk factors for POUR include age, undergoing joint arthroplasty, male sex, intraoperative intravenous fluid administration, operative time, and history of benign prostatic hyperplasia. Indwelling catheterization is the preferred management strategy for patients at risk for developing POUR. A consistent definition of POUR is needed in order to draw conclusions from future studies.
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Affiliation(s)
- Rajiv Karani
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ayman Mahdy
- Departments of Urology (A.M.) and Orthopaedic Surgery (F.A.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Ferhan Asghar
- Departments of Urology (A.M.) and Orthopaedic Surgery (F.A.), University of Cincinnati Medical Center, Cincinnati, Ohio
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Cost-Effectiveness of Arthroplasty Management in Hip and Knee Osteoarthritis: a Quality Review of the Literature. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kranz J, Schmidt S, Wagenlehner F, Schneidewind L. Catheter-Associated Urinary Tract Infections in Adult Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:83-88. [PMID: 32102727 PMCID: PMC7075456 DOI: 10.3238/arztebl.2020.0083] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 07/22/2019] [Accepted: 11/18/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urinary tract infections are among the more common types of nosocomial infection in Germany and are associated with catheters in more than 60% of cases. With increasing rates of antibiotic resistance worldwide, it is essential to distinguish catheter-associated asymptomatic bacteriuria from catheter-associated urinary tract infection (CA-UTI). METHODS This review is based on publications from January 2000 to March 2019 that were retrieved by a selective search in Medline. Randomized clinical trials and systematic reviews in which the occurrence of CA-UTI in adult patients was a primary or secondary endpoint were included in the analysis. Two authors of this review, working independently, selected the publications and extracted the data. RESULTS 508 studies were identified and 69 publications were selected for analysis by the prospectively defined criteria. The studies that were included dealt with the following topics: need for catheterization, duration of catheterization, type of catheter, infection prophylaxis, education programs, and multiple interventions. The duration of catheterization is a determinative risk factor for CA-UTI. The indications for catheterization should be carefully considered in each case, and the catheter should be left in place for the shortest possible time. The available data on antibiotic prophylaxis do not permit any definitive conclusion, but they do show a small benefit from antibiotic-impregnated catheters and from systemic antibiotic prophylaxis. CONCLUSION Various measures, including careful consideration of the indication for catheterization, leaving catheters in place for the shortest possible time, and the training of nursing personnel, can effectively lower the incidence of CA-UTI. The eous in some respects, and thus no recommendations can be given on certain questions relevant to CA-UTI.
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Affiliation(s)
- Jennifer Kranz
- Department of Urology and Pediatric Urology, St. Antonius Hospital Eschweiler, Academic Teaching Hospital of RWTH Aachen, Eschweiler, Germany; UroEvidence, Deutsche Gesellschaft für Urologie, Berlin, Germany; Department of Urology and Kidney Transplantation, Martin Luther University, Halle (Saale), Germany; Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Germany; Department of Urology, University Medicine Rostock, Germany
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Post-operative urinary retention after lower extremity arthroplasty and the peri-operative role of selective alpha-1 adrenergic blocking agents in adult male patients: a propensity-matched retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2019; 44:39-44. [DOI: 10.1007/s00264-019-04420-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
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General Assembly, Prevention, Host Related Local: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S3-S12. [PMID: 30352771 DOI: 10.1016/j.arth.2018.09.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Ma Y, Lu X. Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial. BMC Musculoskelet Disord 2019; 20:11. [PMID: 30611266 PMCID: PMC6320613 DOI: 10.1186/s12891-018-2395-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/26/2018] [Indexed: 01/16/2023] Open
Abstract
Background The purpose of this study was to investigate whether patients undergoing total joint arthroplasty (TJA) require catheterization. Methods PubMed, EMBASE, Web of Science, Cochrane Library and China National Knowledge Infrastructure were systematically searched. All randomized controlled trials (RCTs) receiving either a urinary catheterization or no urinary catheterization were included. Meta-analysis results were assessed by RevMan 5.3 software. Results Seven independent RCTs were included, with a total sample size of 1533 patients, including 750 patients in the indwelling catheter group and 783 patients in the none-indwelling catheter group. Our pooled data analysis indicated that patients in the indwelling catheter group had a higher risk of urinary tract infection than patients in the none-indwelling catheter group (RR, 3.21; P = 0.0003). However, the meta-analysis indicated that there was no significant difference between the two groups in terms of urinary retention (RR, 0.67; P = 0.13), duration of the surgery (MD, − 0.37; P = 0.55), and length of hospital stay (MD, 0.15; P = 0.38). Conclusion Based on the current evidence, this meta-analysis showed that urinary catheterization during TJA can increase the postoperative urinary tract infection, and it may not routinely be required for the patients undergoing TJA. Level of evidence Level I, therapeutic study.
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Affiliation(s)
- Yimei Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, People's Republic of China
| | - Xiaoxi Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, People's Republic of China.
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Meddings J, Skolarus TA, Fowler KE, Bernstein SJ, Dimick JB, Mann JD, Saint S. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Qual Saf 2019; 28:56-66. [PMID: 30100564 PMCID: PMC6365917 DOI: 10.1136/bmjqs-2018-008025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/12/2018] [Accepted: 06/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use. OBJECTIVE Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures. METHODS Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness. RESULTS Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1-4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures. CONCLUSION We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.
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Affiliation(s)
- Jennifer Meddings
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ted A Skolarus
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Justin B Dimick
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jason D Mann
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sanjay Saint
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Lawrie CM, Ong AC, Hernandez VH, Rosas S, Post ZD, Orozco FR. Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia. J Arthroplasty 2017; 32:3748-3751. [PMID: 28781015 DOI: 10.1016/j.arth.2017.07.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/29/2017] [Accepted: 07/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia. METHODS Consecutive patients who underwent a primary THA without preoperative catheterization under spinal anesthesia were identified in a prospectively collected institutional patient database. All patients were monitored postoperatively for urinary retention on the basis of symptoms and the use of bladder ultrasound scans performed by a hospital technician. If necessary, straight catheterization was performed up to 2 times prior to indwelling catheter insertion. RESULTS One hundred eighty patients were included in the study. Six patients who required indwelling catheterization for intraoperative monitoring were excluded. Seventy-six patients experienced POUR and required straight catheterization. Fourteen patients ultimately required indwelling catheterization. One patient who was not catheterized developed a urinary tract infection versus none of the patients who were catheterized. POUR was significantly associated with intraoperative fluid volume and a history of urinary retention (P = .018 and .023, respectively). Intraoperative fluid volumes of 2025, 2325, 2875, and 3800 mL were associated with a specificity for POUR of 60%, 82.7%, 94.9%, and 98%, respectively. No significant associations were found among catheterization and gender, body mass index, American Society of Anesthesiologists class, history of polyuria, history of incontinence, postoperative oral narcotics use, or surgical duration. CONCLUSION Patients with a history of prior urinary retention and those who receive high volumes of intraoperative fluid volume are at higher risk for POUR following THA performed under spinal anesthesia.
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Affiliation(s)
- Charles M Lawrie
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Alvin C Ong
- The Rothman Institute, Egg Harbor Township, New Jersey
| | - Victor H Hernandez
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Samuel Rosas
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Low incidence of postoperative urinary retention with the use of a nurse-led bladder scan protocol after hip and knee arthroplasty: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:283-289. [DOI: 10.1007/s00590-017-2042-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/09/2017] [Indexed: 12/28/2022]
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Altschul D, Kobets A, Nakhla J, Jada A, Nasser R, Kinon MD, Yassari R, Houten J. Postoperative urinary retention in patients undergoing elective spinal surgery. J Neurosurg Spine 2017. [DOI: org/10.3171/2016.8.spine151371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
OBJECTIVE
Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence.
METHODS
The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis.
RESULTS
Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome.
CONCLUSIONS
Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.
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19
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Omitting perioperative urinary catheterization in laparoscopic cholecystectomy: a single-institution experience. Surg Today 2016; 47:928-933. [PMID: 27943036 DOI: 10.1007/s00595-016-1454-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
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20
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Altschul D, Kobets A, Nakhla J, Jada A, Nasser R, Kinon MD, Yassari R, Houten J. Postoperative urinary retention in patients undergoing elective spinal surgery. J Neurosurg Spine 2016; 26:229-234. [PMID: 27767680 DOI: 10.3171/2016.8.spine151371] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence. METHODS The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis. RESULTS Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome. CONCLUSIONS Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.
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Affiliation(s)
- David Altschul
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Andrew Kobets
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Jonathan Nakhla
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Ajit Jada
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Rani Nasser
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Merritt D Kinon
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Reza Yassari
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - John Houten
- Marcus Neuroscience Institute, Boca Raton, Florida
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Iorio R, Clair AJ, Inneh IA, Slover JD, Bosco JA, Zuckerman JD. Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care. J Arthroplasty 2016; 31:343-50. [PMID: 26427938 DOI: 10.1016/j.arth.2015.09.004] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/31/2015] [Accepted: 09/01/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." METHODS A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. RESULTS Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. CONCLUSION Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. LEVEL OF EVIDENCE IV economic and decision analyses-developing an economic or decision model.
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Affiliation(s)
- Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Andrew J Clair
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Ifeoma A Inneh
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - James D Slover
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Joseph D Zuckerman
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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22
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Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0130636. [PMID: 26146830 PMCID: PMC4492963 DOI: 10.1371/journal.pone.0130636] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. Methods We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity. Results Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01). Conclusions Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively. Level of Evidence Level I.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - An Liu
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Dongcai Hu
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Deting Xue
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Chao Li
- Department of Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Kai Zhang
- Department of Nuclear Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Honghai Ma
- Department of Thoracic surgery, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Shigui Yan
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Zhijun Pan
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- * E-mail:
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23
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Iorio R. Strategies and tactics for successful implementation of bundled payments: bundled payment for care improvement at a large, urban, academic medical center. J Arthroplasty 2015; 30:349-50. [PMID: 25680447 DOI: 10.1016/j.arth.2014.12.031] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/09/2014] [Accepted: 12/15/2014] [Indexed: 02/01/2023] Open
Abstract
As health care reform continues to evolve, there will need to be an emphasis on generating value, quality improvement, and cost control. In 2011, the Centers for Medicare and Medicaid Services (CMS) initiated a new Bundled Payment for Care Improvement initiative. Early results from this CMS bundled payment initiative at an urban, tertiary, academic medical center demonstrate decreased length of stay and increased discharge to home, with decreasing readmission rates, which can result in cost-savings without compromise of the quality of care. Changes in care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the bundled payment for care initiative, thus bringing increased value to our total joint arthroplasty patients.
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Affiliation(s)
- Richard Iorio
- Orthopedic Surgery, Department of Orthopedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
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Jung HJ, Park JB, Kong CG, Kim YY, Park J, Kim JB. Postoperative urinary retention following anterior cervical spine surgery for degenerative cervical disc diseases. Clin Orthop Surg 2013; 5:134-7. [PMID: 23730478 PMCID: PMC3664673 DOI: 10.4055/cios.2013.5.2.134] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 10/31/2012] [Indexed: 11/25/2022] Open
Abstract
Background Postoperative urinary retention (POUR) may cause bladder dysfunction, urinary tract infection, and catheter-related complications. It is important to be aware and to be able to identify patients at risk of developing POUR. However, there has been no study that has investigated the incidence and risk factors for the development of POUR following anterior cervical spine surgery for degenerative cervical disc disease. Methods We included 325 patients (164 male and 161 female), who underwent anterior cervical spine surgery for cervical radiculopathy or myelopathy due to primary cervical disc herniation and/or spondylosis, in the study. We did not perform en bloc catheterization in our patients before the operation. Results There were 36 patients (27 male and 9 female) that developed POUR with an overall incidence of 11.1%. The mean numbers of postoperative in-and-out catheterizations was 1.6 times and mean urine output was 717.7 mL. Thirteen out of 36 POUR patients (36%) underwent indwelling catheterization for a mean 4.3 days after catheterization for in-and-out surgery, because of persisting POUR. Seven out of 36 POUR patients (19%) were treated for voiding difficulty, urinary tract irritation, or infection. Chi-square test showed that patients who were male, had diabetes mellitus, benign prostate hypertrophy or myelopathy, or used Demerol were at higher risk of developing POUR. The mean age of POUR patients was higher than non-POUR patients (68.5 years vs. 50.8 years, p < 0.01). Conclusions To avoid POUR and related complications as a result of anterior cervical spine surgery for degenerative cervical disc disease, we recommend that a catheter be placed selectively before the operation in at-risk patients, the elderly in particular, male gender, diabetes mellitus, benign prostate hypertrophy, and myelopathy. We recommend that Demerol not be used for postoperative pain control.
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Affiliation(s)
- Hyun Ju Jung
- Department of Anesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
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Risk factors for urinary retention after hip or knee replacement: a cohort study. Can J Anaesth 2011; 58:1097-104. [PMID: 21989549 PMCID: PMC3219865 DOI: 10.1007/s12630-011-9595-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 09/14/2011] [Indexed: 12/05/2022] Open
Abstract
Introduction In 2006, our provincial government initiated a program to reduce wait times for total hip or knee replacements by referring patients to a single tertiary-care centre. This program provided an opportunity to identify risk factors for perioperative complications as part of a continuing quality improvement project. We report the risk of postoperative urinary retention after hip and knee replacements and the risk factors associated with this complication. Methods After local Research Ethics Board approval, data were abstracted from charts of patients who underwent elective primary unilateral total hip or knee replacement surgery. The outcome was urinary retention in the first 24 hr after surgery. Risk factors were identified using multivariable logistic regression, and they were expressed as odds ratios (OR) or 95% confidence intervals (CI). Results From April 1, 2006 to May 31, 2007, 1,440 patients underwent 1,515 elective total hip replacement or total knee replacement. We abstracted data from 1,031 (71.3%) patients: mean age, 62 yr (interquartile range [IQR] 55-70); 53.7% female; 605 total hip replacements; and 426 total knee replacements. The procedures were performed under spinal (81.8%), general (10.2%), or combined spinal and general (8.0%) anesthesia. Patients spent 100 [IQR 90-114] min in the operating room and 3 [IQR 3-4] days in hospital. The 24-hr incidence of urinary retention was 43.3% (446/1031). Male sex (odds ratio [OR] 3.9; 95% CI 3.0 to 5.2), total hip replacement (OR 1.4; 95% CI 1.1 to 1.9), and intrathecal morphine were risk factors. Discussion Postoperative urinary retention is a common complication after total hip or total knee replacement, especially amongst men and patients receiving intrathecal morphine.
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Kumar P, Mannan K, Chowdhury AM, Kong KC, Pati J. Urinary retention and the role of indwelling catheterization following total knee arthroplasty. Int Braz J Urol 2006; 32:31-4. [PMID: 16519825 DOI: 10.1590/s1677-55382006000100005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2005] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION We aimed to investigate the rate of urinary retention after knee arthroplasty, the various factors involved in predicting those at risk for retention and to assess the impact of retention and catheterization on joint sepsis. MATERIALS AND METHODS A retrospective review was conducted of all available case notes of patients undergoing total knee arthroplasty in a consecutive 2-year period (2000-2002). Adequate data was available for 142 patients. RESULTS 142 patients underwent total knee arthroplasty. 19 patients were catheterized preoperatively for monitoring urine output. 123 patients were not catheterized. Urinary retention occurred in 19.7% (28/142). The mean day of catheterization for retention was 0.66. The mean duration of catheterization in patients developing retention was 3.58 days and was 3 days in the patients catheterized pre- or perioperatively. Deep joint sepsis occurred in 2.1% (3/142)--only one had been catheterized and that was preoperatively. No case of infection had urinary retention or had a symptomatic urinary tract infection. The only factors predicting those at significant risk of retention following knee arthroplasty was a past medical history of urinary retention (p = 0.049) and postoperative morphine requirement (p = 0.035). No patients required urological surgical intervention at mean follow up of 1.97 years. CONCLUSIONS This study supports the use of indwelling urinary catheterization for patients developing urinary retention after total knee arthroplasty.
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Affiliation(s)
- P Kumar
- Department of Urology, Homerton University Hospital, London, UK.
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Stubbs G, Pryke SER, Tewari S, Rogers J, Crowe B, Bridgfoot L, Smith N. Safety and cost benefits of bilateral total knee replacement in an acute hospital. ANZ J Surg 2006; 75:739-46. [PMID: 16173984 DOI: 10.1111/j.1445-2197.2005.03516.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Total knee arthroplasty of both knees under the one anaesthetic has become a common procedure. Benefits reported include a shorter overall hospital stay and reduced costs. The published studies come from university associated tertiary referral hospitals with well-established research establishments and a vast experience of joint replacement. This study examines the experience of a small hospital to see if similar benefits can be achieved. METHODS A retrospective medical record review was performed of the synchronous bilateral knee replacements against a match group of bilateral staged knee replacements. Both groups were compared with a control group of unilateral knee replacements. A prospectively conducted review of the synchronous and staged bilateral knee replacement groups was then carried out to assess the clinical outcome in these two groups. RESULTS The incidence of surgical and medical complications was not statistically different in any group. The bed stay for bilateral surgery was increased by 2 days compared to unilateral surgery with a net saving of 6 days hospital stay for the patient group having both knees replaced at separate operations within 1 year. At an average of 2.5 years post surgery there was no statistically significant difference in outcome between those patients who had both knees replaced either synchronously or at staged intervals. CONCLUSIONS Bilateral knee replacement is a good choice for patient and hospital. Bilateral surgery does not increase the risk of perioperative complications to the patient and reduces the overall cost to the hospital. There is no difference in short to medium term clinical outcome between patients who have had both knees replaced synchronously or at staged intervals. Results comparable in safety, as judged by complication rates and efficiency, as judged by length of stay can be achieved in a smaller metropolitan level 2 hospital environment.
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Affiliation(s)
- Geoffrey Stubbs
- Calvary Health Care ACT, Jamison Centre, Australian Capital Territory, Australia.
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Iorio R, Whang W, Healy WL, Patch DA, Najibi S, Appleby D. The utility of bladder catheterization in total hip arthroplasty. Clin Orthop Relat Res 2005:148-52. [PMID: 15738815 DOI: 10.1097/01.blo.0000149823.57513.00] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The use of a urinary bladder catheter in patients having a total hip arthroplasty is controversial. Universal insertion of an indwelling catheter before a total hip arthroplasty, and insertion of a catheter postoperatively as necessary, are accepted variations of care. From 1993 to 1999, 719 patients having primary, unilateral total hip arthroplasties were randomized by surgeons into two groups: a group of patients who had universal preoperative insertion of an indwelling bladder catheter (340 patients) and an observation group who had catheterization as needed (379 patients). Catheterization was required for 295 of these 379 patients (77.8%). Patients were followed up using a total hip arthroplasty database, which recorded all complications. Six patients (1.8%) in the universal catheter insertion group had a urinary tract infection develop. Nine patients (2.4%) in the catheter as necessary group had a urinary tract infection develop. There was no significant difference in incidence of urinary tract infections between the two groups. Female gender and increasing age were associated with a higher incidence of urinary tract infection in both groups. The average length of stay in the hospital for the universal catheter group was 4.8 days, and the average length of stay for the catheter as necessary group was 4.5 days. There was no significant difference in length of stay in the hospital between the two groups. The universal catheter group had an average 590 dollars higher hospital cost for their total hip arthroplasties, which was significant. Routine preoperative bladder catheterization may not be warranted in patients having total hip arthroplasties. Postoperative catheterization as necessary may be more cost effective.
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Affiliation(s)
- Richard Iorio
- Lahey Clinic Medical Center, Burlington, MA 01805, USA.
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