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Greimel F, Schiegl J, Meyer M, Grifka J, Maderbacher G. [Fast-Track-Arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:117-126. [PMID: 38226987 PMCID: PMC10844365 DOI: 10.1007/s00132-023-04465-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/17/2024]
Abstract
INTRODUCTION Essential components of fast-track or enhanced recovery programs in arthroplasty are the optimization of interdisciplinary organizational processes, as well as pre-, intra- and postoperative procedures in everyday clinical practice. The early postoperative mobilization of patients after joint replacement surgery is of central importance, with the aim of avoiding pain and complications. This article provides a detailed overview of fast-track procedures that have already been established in many units. Furthermore, it demonstrates the clinical advantages of FastTrack for total hip arthroplasty (THA) in an evidence-based manner within the framework of a randomized study design. MATERIAL AND METHODS 194 primary THA patients were examined after randomization into two single-blinded groups; Fast-Track (n = 98) or conventional treatment path (n = 96). Mobilization was defined as the primary outcome parameter, measured in seconds using the Timed Up and Go Test (TUG). Secondary parameters were the achievable walking distance in meters and pain using the numerical rating scale (NRS). All parameters were recorded preoperatively and daily until the sixth postoperative day. RESULTS No complications or revisions were recorded within the first postoperative week. The fast-track group showed significantly better TUG values and walking distance results compared to the conventional group until the sixth postoperative day (p < 0.05, respectively). There was no significant difference regarding the pain assessment (NRS) (p > 0.05). CONCLUSION The use of Fast-Track in hip arthroplasty can evidently improve short-term postoperative clinical outcomes. This first prospective, single-blinded, randomized controlled study showed very good clinical results with comparable pain after FastTrack THA compared to a conventional treatment path. Fast-Track concepts are highly effective in terms of early mobilization and clinical outcome-without incurring a higher risk of complications in the short term.
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Affiliation(s)
- Felix Greimel
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Julia Schiegl
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Matthias Meyer
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Günther Maderbacher
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
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Aderinto N, Olatunji G, Kokori E, Olaniyi P, Isarinade T, Yusuf IA. Recent advances in bariatric surgery: a narrative review of weight loss procedures. Ann Med Surg (Lond) 2023; 85:6091-6104. [PMID: 38098582 PMCID: PMC10718334 DOI: 10.1097/ms9.0000000000001472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/25/2023] [Indexed: 12/17/2023] Open
Abstract
Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity.
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Affiliation(s)
- Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Ogbomoso, Oyo State
| | | | - Emmanuel Kokori
- Department of Medicine and Surgery, University of Ilorin, Ilorin
| | - Peter Olaniyi
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Ogbomoso, Oyo State
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Khatoon MA, Karim SMK, Wasim M, Ali R, Zaighum M, Iqbal N. Frequency of Urinary Tract Infection Among Patients Undergoing Implant Fixation for Acute Trauma. Cureus 2023; 15:e49817. [PMID: 38045632 PMCID: PMC10692962 DOI: 10.7759/cureus.49817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2023] [Indexed: 12/05/2023] Open
Abstract
OBJECTIVE This study aims to determine the frequency of urinary tract infection (UTI), identify the isolated bacteria, and assess antibiotic sensitivity in patients undergoing orthopedic implant fixation for hip fractures. METHODOLOGY After ethical approval from the institutional review board, this retrospective cross-sectional study was conducted at the Orthopedic Surgery Department of Dow University Hospital Karachi from June 2022 to June 2023. Through non-probability consecutive sampling, 186 patients above 16 years of age, of either gender, presenting with hip fractures such as intracapsular or extracapsular fractures, who underwent surgical fixation, were included in the study. A urine sample for urinalysis of these patients was sent on admission. Patients who presented with open fractures or those treated with conservative management were excluded from the study. The fracture diagnosis was confirmed on radiographs. All other relevant baseline investigations were also performed before surgery, per protocol, and urine-detailed and cultured reports were followed. In addition, each patient was asked about common symptoms of UTI before surgery and then diagnosed with UTI on positive urine culture and sensitivity (CS). RESULTS Out of 186 hip fracture patients, 98 (52.7%) were males and 88 (47.3%) were females, with a mean age of 61.03 ± 16.43 (16-96) years. Pre-operative UTI symptoms were reported by 79 patients, including dysuria (16; 20.3%), polyuria (19; 24.0%), and burning (44; 55.7%). UTI was diagnosed on culture and sensitivity report in 65 (34.9%) patients with Escherichia coli as commonly diagnosed bacteria 35 (53.8%), followed by Enterococcus 8 (12.4%), Klebsiella 7 (10.9%), Pseudomonas aeruginosa 3 (4.7%), and Acinetobacter 2 (3.1%) patients. E. coli was sensitive to amikacin, amoxicillin/clavulanic acid, ampicillin, cefixime, ceftriaxone, cefuroxime, ciprofloxacin, colistin, cotrimoxazole, fosfomycin, gentamycin, levofloxacin, meropenem, nitrofurantoin, polymyxin B, and piperacillin-tazobactam. CONCLUSION Urinary tract infection is common in patients undergoing orthopedic implant fixation for hip fractures, which can lead to potentially serious outcomes. Overall, hygiene, prompt treatment, and standard protocol should be utilized to treat those infected and minimize the spread.
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Affiliation(s)
- Malik Amna Khatoon
- Orthopaedic Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Syed Muhammad Khalid Karim
- Orthopaedics and Trauma, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Muhammad Wasim
- Orthopaedic Surgery, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Rufina Ali
- Trauma and Orthopaedics, Shaheed Mohtarma Benazir Bhutto Institute of Trauma (SMBBIT), Karachi, PAK
| | - Mariam Zaighum
- Orthopaedics and Trauma, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Naveed Iqbal
- Trauma and Orthopaedics, Shaheed Mohtarma Benazir Bhutto Institute of Trauma (SMBBIT), Karachi, PAK
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Piple AS, Wang JC, Kebaish KJ, Mills ES, Oakes DA, Lieberman JR, Christ AB, Heckmann ND. Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty? J Arthroplasty 2023; 38:1024-1031. [PMID: 36566997 DOI: 10.1016/j.arth.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/14/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Prednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA. METHODS A national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not. RESULTS After controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate. CONCLUSION Patients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.
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Affiliation(s)
- Amit S Piple
- Keck School of Medicine of USC, Los Angeles, California
| | | | | | - Emily S Mills
- Keck School of Medicine of USC, Los Angeles, California
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Knoedler S, Kauke-Navarro M, Haug V, Broer PN, Pomahac B, Knoedler L, Panayi AC. Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis. Aesthet Surg J 2023; 43:433-451. [PMID: 36472232 DOI: 10.1093/asj/sjac320] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction. OBJECTIVES The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care. METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed. RESULTS In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications. CONCLUSIONS This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.
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Clinically predictive baseline labs for post-operative outcomes of brain tumors using NSQIP database. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:825-831. [PMID: 36781309 DOI: 10.1016/j.ejso.2023.01.028] [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: 02/04/2022] [Revised: 01/15/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE This study was performed to assess the effect of baseline Preoperative Laboratory Values (PLV) on post-operative Brain Tumor Resection (BTR) outcomes in a large national registry. METHODS We extracted data from the National Surgical Quality Improvement Program (NSQIP) database for BTR patients 2015-2019 (n = 3 0,951). Uni- and multivariate analyses were performed for PLV and key surgical outcomes. RESULTS The most significant PLV predictors of 30-day mortality after BTR included hypernatremia (odds ratio, OR 4.184, 95% CI, 2.384-7.343, p < 0.001), high serum creatinine (OR 2.244, 95% CI 1.502-3.352, p < 0.001), thrombocytopenia (OR 1.997, 95% CI 1.438, 2.772, p < 0.001), and leukocytosis (OR 1.635, 95% CI 1.264, 2.116, p < 0.001). The most significant predictors of Clavien IV complications were increased INR (OR 2.653, 95% CI 1.444, 4.875, p < 0.01), thrombocytopenia (OR 1.514, 95% CI 1.280, 1.792, p < 0.001), hypoalbuminemia (OR 1.480, 95% CI 1.274, 1.719, p < 0.001), and leukocytosis (OR 1.467, 95% CI 1.306, 1.647, p < 0.001). The most robust predictors of eLOS were increased INR (OR 1.941, 95% CI 1.231, 3.060, p < 0.01) and hypoalbuminemia (OR 1.993, 95% CI 1.823, 2.179, p < 0.001), and those for non-routine discharge included increased INR (OR 1.897, 95% CI 1.196, 3.008, p < 0.01) and hypernatremia (OR 1.565, 95% CI 1.217, 2.012, p < 0.001). CONCLUSIONS Several PLV independently predicted worse outcomes in BTR patients. Baseline labs should be routinely used for the pre-operative risk stratification of these patients.
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Tennison JM, Pally A, Fellman BM, Westney OL, Bruera E. Urinary Dysfunction: Frequency, Risk factors, and Interventions in patients with Cancer during Acute Inpatient Rehabilitation. J Cancer 2023; 14:299-305. [PMID: 36741257 PMCID: PMC9891869 DOI: 10.7150/jca.80620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/25/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction: Urinary dysfunction has a strong impact clinically, socially, and economically. Although the development of acute urinary dysfunction in hospitalized patients with cancer is common in clinical practice, its occurrence and management strategies are scant in the literature. It has been reported as one of the more common medical complications in patients with cancer undergoing acute inpatient rehabilitation. This study assessed the frequency of and risk factors for acute urinary dysfunction among these patients and identified the interventions used for management. Methods: This is a retrospective study of consecutive patients admitted to a National Cancer Institute Comprehensive Cancer Center's acute inpatient rehabilitation service from 9/1/2020 through 3/15/2021. We excluded patients that were readmissions during the study time frame. We collected patients' demographic, clinical, and functional data. We defined acute urinary dysfunction as the development of any new urinary symptom(s) or diagnosis, which involved additional work-up and/or management after admission to the acute inpatient rehabilitation service. Results: Of the 176 total patients included in this study, 47 (27%; 95% confidence interval [CI], 20-34) patients had acute urinary dysfunction. The most frequent diagnoses were urinary tract infection (32%) and neurogenic bladder (26%). The most common tests were urine cultures (32%) and urinalyses (30%). The most commonly prescribed medications were antibiotics (32%) and alpha-1 blockers (15%). Other most frequent interventions included timed voiding (34%) and intermittent catheterization with bladder scans (28%). Acute urinary dysfunction was associated with an increased length of stay on the inpatient rehabilitation service (odds ratio [OR], 1.13; 95% CI, 1.06-1.20; P<.001), surgery during the index admission (OR, 2.50; 95% CI, 1.21-5.16; P=.014), and fecal incontinence (OR, 6.41; 95% CI, 1.83-22.44; P=.004). Conclusion: Acute urinary dysfunction was noted to be a substantial problem in this cohort. This is an overlooked dimension of inpatient cancer rehabilitation that deserves more attention. Patients at risk for acute urinary dysfunction may benefit from close monitoring for medical management and rehabilitation interventions to maximize functional independence with bladder care. More research regarding acute urinary dysfunction types and management approaches in post-acute care settings for patients with cancer is justified.
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Affiliation(s)
- Jegy Mary Tennison
- Section of Physical Medicine & Rehabilitation, Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Annie Pally
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Bryan Michael Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ouida Lenaine Westney
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Section of Palliative Medicine, Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Lung B, Callan K, McLellan M, Kim M, Yi J, McMaster W, Yang S, So D. The impact of dehydration on short-term postoperative complications in total knee arthroplasty. BMC Musculoskelet Disord 2023; 24:15. [PMID: 36611176 PMCID: PMC9825029 DOI: 10.1186/s12891-022-06118-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND As healthcare economics shifts towards outcomes-based bundled payment models, providers must understand the evolving dynamics of medical optimization and fluid resuscitation prior to elective surgery. Dehydration is an overlooked modifiable risk factor that should be optimized prior to elective total knee arthroplasty (TKA) to reduce postoperative complications and inpatient costs. METHODS All primary TKA from 2005 to 2019 were queried from the National Surgical Quality Improvement Program (NSQIP) database, and patients were compared based on dehydration status: Blood Urea Nitrogen Creatinine ratio (BUN/Cr) < 20 (non-dehydrated), 20 ≤ BUN/Cr ≤ 25 (moderately-dehydrated), 25 < BUN/Cr (severely-dehydrated). A sub-group analysis involving only elderly patients > 65 years and normalized gender-adjusted Cr values was also performed. RESULTS The analysis included 344,744 patients who underwent TKA. Adjusted multivariate logistic regression analysis showed that the severely dehydrated cohort had a greater risk of non-home discharge, postoperative transfusion, postoperative deep vein thrombosis (DVT), and increased length of stay (LOS) (all p < 0.01). Among the elderly, dehydrated patients had a greater risk of non-home discharge, progressive renal insufficiency, urinary tract infection (UTI), postoperative transfusion, and extended LOS (all p < 0.01). CONCLUSION BUN/Cr > 20 is an important preoperative diagnostic tool to identify at-risk dehydrated patients. Providers should optimize dehydration to prevent complications, decrease costs, and improve discharge planning. LEVEL OF EVIDENCE Level III; Retrospective Case-Control Design; Prognosis Study.
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Affiliation(s)
- Brandon Lung
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - Kylie Callan
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - Maddison McLellan
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - Matthew Kim
- grid.36425.360000 0001 2216 9681Department of Orthopaedic Surgery, Stony Brook University School of Medicine, NY Stony Brook, USA
| | - Justin Yi
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - William McMaster
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - Steven Yang
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
| | - David So
- grid.266093.80000 0001 0668 7243Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Dr S Pavilion 3, CA 92868 Orange, USA
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Tuddenham SA, Gearhart SL, Wright Iii EJ, Handa VL. Frailty and postoperative urinary tract infection. BMC Geriatr 2022; 22:828. [PMID: 36307754 PMCID: PMC9617308 DOI: 10.1186/s12877-022-03461-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among older adults, postoperative urinary tract infection is associated with significant harms including increased risk of hospital readmission and perioperative mortality. While risk of urinary tract infection is known to increase with age, the independent association between frailty and postoperative urinary tract infection is unknown. In this study we used 2014-2018 data from the U.S. National Surgical Quality Improvement Program (NSQIP) to investigate whether frailty is an independent risk factor for postoperative urinary tract infection, controlling for age and other relevant confounders. METHODS Frailty was assessed using the modified Frailty Index. Postoperative urinary tract infection was defined as any symptomatic urinary tract infection (of the kidneys, ureters, bladder, or urethra) developing within 30 days of the operative procedure. To examine associations between frailty and other specific factors and postoperative urinary tract infection, chi squared tests, students t-tests, and logistic regression modelling were used. RESULTS Urinary tract infection was identified after 22,356 of 1,724,042 procedures (1.3%). In a multivariable model controlling for age and other patient and surgical characteristics, the relative odds for urinary tract infection increased significantly with increasing frailty score. For example, compared to a frailty score of 0, the relative odds for urinary tract infection for a frailty score of 3 was 1.50 (95% confidence interval 1.41, 1.60). The relative odds associated with the maximum frailty score (5) was 2.50 (95% confidence interval 1.73, 3.61). CONCLUSIONS Frailty is associated with postoperative urinary tract infection, independent of age. Further research should focus on the underlying mechanisms and strategies to mitigate this risk among frail adults.
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Affiliation(s)
- Susan A Tuddenham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E James Wright Iii
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victoria L Handa
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Swiggett SJ, Mannino A, Vakharia RM, Ehiorobo JO, Roche MW, Mont MA, Erez O. Impact of Biological Sex on Complications, Lengths of Stay, Readmission Rates, and Costs of Care Following Primary Total Knee Arthroplasty. J Knee Surg 2022; 35:1306-1311. [PMID: 33545731 DOI: 10.1055/s-0041-1723014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The impact of gender on total knee arthroplasty (TKA) postoperative complications, readmission rates, and costs of care has not been often evaluated. Therefore, the purpose of this study was to investigate which sex had higher rates of: (1) medical complications; (2) implant complications; (3) lengths of stay (LOSs); (4) readmission rates; and (5) costs after TKA. A query was performed using an administrative claims database from January 1, 2005, to March 31, 2015. Patients who had TKAs were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Males and females were filtered separately and matched according to age and various medical comorbidities leading to 1,590,626 patients equally distributed. Primary outcomes analyzed included 90-day medical complications, LOSs, 90-day readmission rates, in addition to day of surgery and total global 90-day episode of care costs. Pearson's chi-square analyses were used to compare medical complications and readmission rates. Welch's t-tests were used to test for significance in matching outcomes and costs. A p-value of less than 0.01 was considered statistically significant. Males had a smaller risk of complications than women (1.35 vs. 1.40%, p < 0.006) and higher rates of implant-related complications (2.28 vs. 1.99%, p < 0.0001). Mean LOSs were lower for males: 3.16 versus 3.34 days (p < 0.0001). The 90-day readmission rates were higher in men (9.67 vs. 8.12%, p < 0.0001). This study demonstrated that males undergoing primary TKA have lower medical complications and shorter LOSs then their female counterparts. However, males have higher implant-related complications, readmission rates, and costs of care.
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Affiliation(s)
- Samuel J Swiggett
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Angelo Mannino
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Rushabh M Vakharia
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Martin W Roche
- Department of Orthopaedic Surgery, Holy Cross Hospital, Ft. Lauderdale, Florida
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, Manhattan, New York
| | - Orry Erez
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
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Incidence, risk factors and clinical implications of postoperative urinary tract infection in geriatric hip fractures. Injury 2022; 53:2158-2162. [PMID: 35339273 DOI: 10.1016/j.injury.2022.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 03/02/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Postoperative urinary tract infection (UTI) is common in geriatric patients; however, little is known about the impact of UTI in orthopedic trauma. The present study was designed to determine the risk factors and clinical impact of postoperative urinary tract infection (UTI) in acute geriatric hip fractures. PATIENTS AND METHODS Geriatric patients (≥65 years of age) undergoing hip fracture surgery were identified within the American College of Surgeons National Surgical Quality Improvement Program between 2016 and 2019. Patients presenting with UTI at the time of surgery were excluded. Baseline characteristics and outcomes were compared between patients with and without postoperative UTI. Multivariate logistic regression was performed, controlling for potential confounders. RESULTS A total of 46,263 patients included in the study. Overall, 1,397 (3.02%) patients had postoperative UTI. Patients who developed postoperative UTI had higher rates of pneumonia (6.44% vs. 3.76%, p < 0.001), DVT (2.22% vs. 1.04%, p < 0.001), sepsis (7.73% vs. 0.62%, p < 0.001), and more frequently experienced postoperative hospital lengths of stay exceeding 6 days (37.94% vs. 20.33%, p < 0.001). Hospital readmission occurred more frequently in patients with postoperative UTI (24.55% vs. 7.85%, p < 0.001), but surprisingly, these patients had a lower mortality rate (1.36% vs. 2.2%, p < 0.001). Adjusted analysis demonstrated the following variables associated with postoperative UTI: age ≥ 85 (OR = 1.37, 95%CI = 1.08 - 1.73), ASA class ≥ 3 (OR = 1.59, 95%CI = 1.21 - 2.08,), chronic steroid use (OR = 1.451, 95%CI = 1.05 - 1.89), blood transfusion (OR = 1.24, 95%CI = 1.05 - 1.48), and >2 days delay from admission to operation (OR = 1.37, 95%CI = 1.05 - 1.79). Postoperative UTI was significantly associated with sepsis (OR = 7.65, 95%CI = 5.72 - 10.21), postoperative length of stay >2 days (OR = 1.83, 95%CI = 1.07 - 3.13), and readmission (OR = 3, 95%CI = 2.54 - 3.55). CONCLUSIONS In our study, postoperative UTI was found in 3% of geriatric hip fracture patients. Predictors of postoperative UTI were age ≥ 85, ASA class ≥ 3, chronic steroid use, blood transfusion, and time to operation > 2 days from admission. Results showed that postoperative UTI is independently associated with sepsis, postoperative length of stay beyond 2 days, and hospital readmission. To diminish the risk of UTI and its consequences, we recommend operating geriatric hip fractures in 24-48 hours after admission.
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12
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Greimel F, Maderbacher G. [Perioperative management in fast-track arthroplasty]. DER ORTHOPADE 2022; 51:366-373. [PMID: 35412089 DOI: 10.1007/s00132-022-04244-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Abstract
The optimization of organizational processes, as well as surgical procedures intra- and perioperatively, are essential components with respect to fast-track programs in clinical routine. Treatment concepts focus on early postoperative mobilization of patients after joint replacement surgery in an interdisciplinary setting to avoid pain and complications on a scientific basis. This article gives a comprehensive and detailed overview regarding evidence-based peri- and intraoperative fast-track treatment methods: from pain treatment with intraoperative local infiltration analgesia and tranexamic acid application under minimally invasive surgical approach in short-lasting spinal anesthesia to renunciation of drains, regional pain- and urinary catheters, tourniquets, and restrictions.
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Affiliation(s)
- Felix Greimel
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Günther Maderbacher
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
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13
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Crespi Z, Ismail A, Awad ME, Hasan AI, Irfan FB, Jaffar M, El-Othmani MM, Saleh KJ. Hospital-Acquired Conditions: A Review of Classical and Novel Risk Factors Following Total Hip and Knee Arthroplasties. JBJS Rev 2021; 9:01874474-202107000-00006. [PMID: 34270501 DOI: 10.2106/jbjs.rvw.20.00240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $41,000 per patient per HAC. » In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of >35 kg/m2, male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections. » Institution-specific (surgical) risk factors such as increased tourniquet time, an operative time of >130 minutes, bilateral procedures, a femoral nerve block, and general anesthesia increase the risk of HACs in the settings of THA and TKA.
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Affiliation(s)
- Zachary Crespi
- Central Michigan University College of Medicine, Mount Pleasant, Michigan
| | - Aya Ismail
- University of Michigan, Dearborn, Michigan
| | - Mohamed E Awad
- FAJR Scientific, Northville, Michigan.,Saleh Medical Innovations Consulting, PLLC, Northville, Michigan.,NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Michigan State University, College of Osteopathic Medicine, Detroit, Michigan
| | - Ahmad I Hasan
- FAJR Scientific, Northville, Michigan.,Saleh Medical Innovations Consulting, PLLC, Northville, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| | - Furqan B Irfan
- Michigan State University, College of Osteopathic Medicine, Detroit, Michigan
| | - Muhammad Jaffar
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan
| | | | - Khaled J Saleh
- FAJR Scientific, Northville, Michigan.,Saleh Medical Innovations Consulting, PLLC, Northville, Michigan.,Michigan State University, College of Osteopathic Medicine, Detroit, Michigan
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14
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Nguyen AQ, Foy MP, Sood A, Gonzalez MH. Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties. J Arthroplasty 2021; 36:734-738. [PMID: 32847708 DOI: 10.1016/j.arth.2020.08.002] [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: 06/25/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Establishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA). METHODS This was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations. RESULTS In a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m2 were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m2 were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA. CONCLUSION This study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.
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Affiliation(s)
- Austin Q Nguyen
- Department of Orthopaedic Surgery, University of Illinois, Chicago, IL
| | - Michael P Foy
- Department of Orthopaedic Surgery, University of Illinois, Chicago, IL
| | - Anshum Sood
- Department of Orthopaedic Surgery, University of Illinois, Chicago, IL
| | - Mark H Gonzalez
- Department of Orthopaedic Surgery, University of Illinois, Chicago, IL
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Ziółkowski G, Pawłowska I, Stasiowski M, Jachowicz E, Wójkowska-Mach J, Bielecki T. Multidrug-Resistant Micro-Organisms Associated with Urinary Tract Infections in Orthopedic Patients: A Retrospective Laboratory-Based Study. Antibiotics (Basel) 2020; 10:antibiotics10010007. [PMID: 33374781 PMCID: PMC7823999 DOI: 10.3390/antibiotics10010007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 01/24/2023] Open
Abstract
Background: The risk of healthcare-associated infections (HAIs) in surgical wards remains closely related to the type of surgery and procedures performed on patients. Those factors also condition the risk of various forms of clinical infections, especially urinary tract infections (UTIs). UTIs are most frequently (70–80% of cases) caused by the use of bladder catheter in the perioperative period. The aim of this study was to perform an epidemiological and microbiological analysis of UTIs in orthopedic patients, with an emphasis on multidrug-resistant (MDR) micro-organisms. Methods: The study was conducted in a 38-bed Department of Orthopedic-Traumatic Surgery in Sosnowiec, Poland. 5239 patients, operated on in 2013–2015, were included in the study. The urinary catheter use rate was 30.7%. Laboratory-based study used the UTI definition of the HAI-Net program. A micro-organism was declared MDR if it was resistant to at least one antibiotic from three or more groups of antibacterial drugs, and extensively drug-resistant (XDR) if it was sensitive to antibiotics from no more than two groups of drugs. Results: The UTI incidence was 3.2% (168 cases), the CA-UTI incidence density was 9.6/1000 catheter days. The highest risk of UTI was found in patients aged 75 or older. Monomicrobial cultures were detected in 163 specimens (78% of all microbiologically confirmed UTIs). Gram-negative flora prevailed among the micro-organisms, the predominantly isolated Enterobacteriaceae being Escherichiacoli and Klebsiellapneumoniae. In 16 patients (7.7% of microbiologically confirmed UTIs), yeast infection was confirmed. Isolated micro-organisms were fully sensitive to carbapenems. Gram-negative bacilli showed the lowest sensitivity to extended substrate spectrum penicillins and fluoroquinolones (37–64%), as well as to trimethoprim-sulfamethoxazole (50%). The MDR prevalence was 24.4%. Conclusions: The presented data indicates that UTIs are a significant problem in the studied population, so is antimicrobial resistance, especially to quinolones, and extended-spectrum cephalosporins, which are often used as first-line therapy. To tackle the problem of high UTI incidence and MDR prevalence, reducing the UTI risk factors should be prioritized.
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Affiliation(s)
- Grzegorz Ziółkowski
- Sosnowiec Medical College, Wojska Polskiego 6 Str., 41-200 Sosnowiec, Poland;
| | - Iwona Pawłowska
- Division of Microbiology and Epidemiology, St. Barbara Specialised Regional Hospital No. 5, Medyków 1 Square, 41-200 Sosnowiec, Poland;
| | - Michał Stasiowski
- Clinical Department of Anaesthesiology and Intensive Therapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland;
- Department of Anaesthesiology and Intensive Therapy, St. Barbara’s Memorial Regional Hospital in Sosnowiec, Plac Medyków 1, 41-200 Sosnowiec, Poland
| | - Estera Jachowicz
- Department of Microbiology, Faculty of Medicine Jagiellonian University Medical College, 31-121 Kraków (Cracow), Poland;
- Correspondence: ; Tel.: +48-12-633-00-60; Fax: +48-12-423-39-24
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine Jagiellonian University Medical College, 31-121 Kraków (Cracow), Poland;
| | - Tomasz Bielecki
- Department of Orthopedics of the Faculty of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland;
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Lee D, Lee R, Cross MT, Iweala U, Weinreb JH, Falk DP, O'Brien JR, Yu W. Risk Factors for Postoperative Urinary Tract Infections Following Anterior Lumbar Interbody Fusion. Int J Spine Surg 2020; 14:493-501. [PMID: 32986569 DOI: 10.14444/7065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Although risk factors contributing to UTI have been studied in posterior approaches to lumbar fusion, there is a lack of literature on factors contributing to UTI in anterior lumbar interbody fusion (ALIF). Our purpose was to identify preoperative independent risk factors for postoperative urinary tract infection (UTI) following anterior lumbar interbody fusion (ALIF) so that surgeons may be able to initiate preventative measures and minimize the risk of UTI-related morbidity following ALIF. METHODS The American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify 10 232 patients who had undergone ALIF from 2005 to 2016; 144 patients (1.41%) developed a postoperative UTI while 10 088 patients (98.59%) did not. Univariate analyses were conducted to compare the 2 cohorts' demographics and preoperative comorbidities. Multivariate logistic regression models were then utilized to identify significant predictors of postoperative UTI following ALIF while controlling for differences seen in univariate analyses. RESULTS Age ≥ 60 years (P = .022), female sex (P < .001), alcohol use (P = .014), open wound or wound infections (P = .019), and steroid use (P = .046) were independent risk factors for postoperative UTI. Longer operative times were also independent predictors for developing UTI: 120 minutes ≤ x < 180 minutes (P = .050), 180 minutes ≤ x < 240 minutes (P = .025), and ≥ 240 minutes (P = .001). Postoperative UTI independently increased the risk for pneumonia, blood transfusions, sepsis, thromboembolic events, and extended length of stay as well. CONCLUSIONS Age ≥ 60 years, female sex, alcohol use, steroid use, and open wound or wound infections independently increased the risk for UTI following ALIF. Future work analyzing the efficacy of tapering alcohol and steroid use preoperatively and reducing procedural time with the aim of lowering UTI risk is warranted. Preoperative wound care is strongly encouraged to decrease UTI risk. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Danny Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, D.C
| | - Ryan Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, D.C
| | - Megan T Cross
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, D.C
| | - Uchechi Iweala
- Department of Orthopaedic Surgery, The George Washington University, Washington, D.C
| | - Jeffrey H Weinreb
- Department of Orthopaedic Surgery, The George Washington University, Washington, D.C
| | - David P Falk
- Department of Orthopaedic Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R O'Brien
- Washington Spine and Scoliosis Clinic, OrthoBethesda, Bethesda, Maryland
| | - Warren Yu
- Department of Orthopaedic Surgery, The George Washington University, Washington, D.C
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Tihista M, Gu A, Wei C, Weinreb JH, Rao RD. The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery. J Clin Orthop Trauma 2020; 11:921-927. [PMID: 32904286 PMCID: PMC7452358 DOI: 10.1016/j.jcot.2020.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/07/2020] [Accepted: 04/04/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Corticosteroids have a negative impact on the human immune system's ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine. METHODS A retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment. RESULTS 26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024). CONCLUSION Long-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.
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Key Words
- ACS NSQIP, American College of Surgery National Surgical Quality Improvement Program
- ANOVA, Analysis of Variance
- ASA, American Society of Anesthesiologists
- BMI, Body Mass Index
- CPT, Current Procedure Terminology
- Complications
- Corticosteroid use
- DM, diabetes mellitus
- ICD, International Classification of Disease
- IDDM, Insulin Dependent Diabetes Mellitus
- IL, Interleukin
- LOS, Length of Stay
- Lumbar decompression
- MAC/IV, Monitored Anesthesia Care, Intravenous: NIDDM
- NIDDM, Non-Insulin dependent diabetes mellitus
- National surgical quality improvement program
- OR, Odds Ratio
- UTI, Urinary Tract Infection
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Affiliation(s)
- Mikel Tihista
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Chapman Wei
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Jeffrey H. Weinreb
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Raj D. Rao
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
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Outcomes of Elective Total Hip Arthroplasty in Nonagenarians and Centenarians. J Arthroplasty 2020; 35:2149-2154. [PMID: 32312644 DOI: 10.1016/j.arth.2020.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Nonagenarians and centenarians are among the fastest growing demographics in the United States. Although consequent demand for joint replacement is projected to rise precipitously, outcomes of total hip arthroplasty (THA) have seldom been studied in this population. METHODS A retrospective cohort of patients undergoing primary THA was established using the 2008-2017 American College of Surgeons National Quality Improvement Program. Propensity scores were used to match 858 patients aged 90 or older to 858 patients aged 65-89, controlling for demographic factors and comorbidities. Thirty-day outcomes were compared between matched age cohorts using multiple regression modeling. RESULTS Statistically equivalent 30-day rates of surgical infection (P = .73), pneumonia (P = .39), deep venous thrombosis/thrombophlebitis (P = .55), pulmonary embolism (P = .69), stroke (P = .73), myocardial infarction (P = .44), cardiac arrest (P = .69), and sepsis (P = .77) were observed between matched age cohorts, although nonagenarians and centenarians were significantly more likely to experience urinary tract infection (2.8% vs 0.9%, P = .004). In addition, matched patients aged 90 or older were more likely to have longer hospital stays (3.52 vs 2.81 days, P < .001) and be discharged to a nonhome facility (75.4% vs 34.6%, P < .001) but were at no higher than 30-day risk of reoperation (P = .45), readmission (P = .23), or mortality (P = .59). CONCLUSION Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. Patient comorbidity profiles, rather than age, should principally guide shared clinical decision making.
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Dreyfus J, Yu H, Begier E, Gayle J, Olsen MA. Incidence of Staphylococcus aureus Infections After Elective Surgeries in US Hospitals. Clin Infect Dis 2020; 73:e2635-e2646. [DOI: 10.1093/cid/ciaa913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/30/2020] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Although Staphylococcus aureus is a leading cause of postsurgical infections, national estimates of these infections after elective surgeries based on microbiology data are limited. This study assessed cumulative 180-day postsurgical S. aureus incidence in real-world hospital settings.
Methods
A retrospective study of adults (≥18 years) undergoing inpatient or hospital-based outpatient elective surgeries from 1/7/2010–30/6/2015 at hospitals (N = 181) reporting microbiology results in the Premier Healthcare Database (PHD). 86 surgical categories were identified from the National Healthcare Safety Network procedures. We classified positive S. aureus cultures using a hierarchy (bloodstream [BSI], surgical site [SSI], and all other types [urinary tract, respiratory, other/unknown site]) and calculated incidence (number of infections divided by the number of elective surgery discharges). We estimated national infection case volumes by multiplying incidence by national inpatient elective surgical discharge estimates using the entire PHD and weights based on hospital characteristics.
Results
Following 884 803 inpatient elective surgical discharges, 180-day S. aureus infection incidence was 1.35% (0.30% BSI, 0.74% SSI no BSI, 0.32% all other types only). Among 1 116 994 hospital-based outpatient elective surgical discharges, 180-day S. aureus incidence was 1.19% (0.25% BSI, 0.75% SSI no BSI, 0.19% all other types only). Methicillin resistance was observed in ~45% of the S. aureus infections. We estimated 55 764 S. aureus postsurgical infections occurred annually in the US following 4.2 million elective inpatient surgical discharges.
Conclusions
The high burden of S. aureus infections after both inpatient and outpatient elective surgeries highlights the continued need for surveillance and novel infection prevention efforts.
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Affiliation(s)
- Jill Dreyfus
- Premier Applied Sciences, Premier, Inc, Charlotte, North Carolina, USA
| | - Holly Yu
- Health Economics and Outcomes Research, Pfizer, Inc, Collegeville, Pennsylvania, USA
| | - Elizabeth Begier
- Pfizer Vaccine Research and Development; Pfizer, Inc, Pearl River, New York, USA
| | - Julie Gayle
- Premier Applied Sciences, Premier, Inc, Charlotte, North Carolina, USA
| | - Margaret A Olsen
- Department of Medicine and Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Kittle H, Ormseth A, Patetta MJ, Sood A, Gonzalez MH. Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000001. [PMID: 32672719 PMCID: PMC7366416 DOI: 10.5435/jaaosglobal-d-20-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.
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Affiliation(s)
- Haley Kittle
- From the Department of Orthopaedics, University of Illinois College of Medicine (Ms. Kittle and Dr. Ormseth), and the Department of Orthopaedics, University of Illinois College of Medicine (Dr. Patetta, Dr. Sood, and Dr. Gonzalez), Chicago, IL
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Clarius M, Clarius LM. [Fast-track arthroplasty-intra- and post-operative management]. DER ORTHOPADE 2020; 49:318-323. [PMID: 31974634 DOI: 10.1007/s00132-020-03867-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fast-track concepts in hip and knee arthroplasty focus on an early and safe mobilisation after surgery using a multi-modal pain concept with local infiltration anaesthesia. No drains, femoral nerve blocks or urinary catheters are used. Tranexamic acid reduces blood loss and transfusion rates. Cortisone is helpful in reducing pain, PONV and postsurgical stress response. Minimal invasive surgical techniques and the renouncement of a tourniquet lead to a better functional result and less pain. Restrictions and precautions are not evidence-based and should, therefore, be abandoned.
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Affiliation(s)
- M Clarius
- Vulpius Klinik GmbH, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.
| | - L M Clarius
- Vulpius Klinik GmbH, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
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Preoperative Dehydration does not Increase the Risk of Complications Following Elective Lumbar Surgery. Spine (Phila Pa 1976) 2019; 44:E1336-E1341. [PMID: 31689256 DOI: 10.1097/brs.0000000000003149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions. SUMMARY OF BACKGROUND DATA Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described. METHODS An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20. RESULTS Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified. CONCLUSION Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE 3.
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Ranson WA, Neifert SN, Cheung ZB, Mikhail CM, Caridi JM, Cho SK. Predicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices. World Neurosurg 2019; 134:e487-e496. [PMID: 31669536 DOI: 10.1016/j.wneu.2019.10.102] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to determine the ability of the Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) to predict postoperative complications after anterior cervical discectomy and fusion (ACDF). METHODS This was a retrospective study of ACDF hospitalizations in the National Inpatient Sample from 2013 to 2014. The ECI and CCI were calculated, and patients who experienced postoperative complications were identified. The ability of these indexes to predict complications was compared using the c statistic (area under the receiver operating characteristic curve [AUC]). In addition, the CCI and ECI were compared with a base model that included age, sex, race, and primary payer. RESULTS A total of 261,780 patients were included. Patients who experienced a complication were more often male (P < 0.0001) and older (P < 0.0001). They also had a higher comorbidity burden as assessed by both the ECI (P < 0.0001) and the CCI (P < 0.0001). The ECI was superior in predicting airway complications (AUC, 0.81 vs. 0.75; P < 0.0001), hemorrhagic anemia (AUC, 0.67 vs. 0.63; P = 0.0015), pulmonary embolism (AUC, 0.91 vs. 0.77; P < 0.0001), wound dehiscence (AUC, 0.80 vs. 0.55; P = 0.0080), sepsis (AUC, 0.87 vs. 0.82; P = 0.0001), and septic shock (AUC, 0.94 vs. 0.83; P < 0.0001). The CCI was not found to be superior to the ECI for predicting any complications. Both were excellent for predicting mortality (ECI AUC, 0.87; CCI AUC, 0.90). CONCLUSIONS The ECI was superior to the CCI in predicting 6 of 15 complications in this study. Both are excellent tools for predicting mortality after ACDF.
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Affiliation(s)
- William A Ranson
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | | | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA.
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Scotting OJ, North WT, Chen C, Charters MA. Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia. J Arthroplasty 2019; 34:2324-2328. [PMID: 31303377 DOI: 10.1016/j.arth.2019.05.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia. METHODS Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups. RESULTS Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days. CONCLUSION Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia. LEVEL OF EVIDENCE Level II, retrospective comparative study.
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Affiliation(s)
- Oliver J Scotting
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Wayne T North
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Chaoyang Chen
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Michael A Charters
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
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Ishigami J, Trevisan M, Xu H, Coresh J, Matsushita K, Carrero JJ. Estimated GFR and Hospital-Acquired Infections Following Major Surgery. Am J Kidney Dis 2018; 73:11-20. [PMID: 30201545 DOI: 10.1053/j.ajkd.2018.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE Low estimated glomerular filtration rate (eGFR) increases infection risk, but its contribution to hospital-acquired infection following major surgery is unknown. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Residents of Stockholm, Sweden, 18 years or older with at least 1 recorded serum creatinine measurement, no recent diagnoses of infection, and hospitalized for orthopedic, abdominal, cardiothoracic and vascular, or neurologic surgery between January 2007 and December 2011. EXPOSURES: eGFR<60mL/min/1.73m2 (termed low eGFR) and other clinical comorbid conditions at admission: cancer, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, heart failure (HF), and liver disease. OUTCOMES Incidence and population-attributable fractions of 4 major types of hospital-acquired infections: pneumonia, urinary tract infection, surgical-site infection, and bloodstream infection. ANALYTICAL APPROACH Logistic regression analysis. RESULTS 66,126 patients with a history of orthopedic (n=31,630), abdominal (n=26,317), cardiothoracic and vascular (n=6,266), or neurologic (n=1,913) surgery were studied. Cancer (21%) and low eGFR (18%) were the most prevalent comorbid conditions at admission, followed by diabetes, HF, and COPD (12%). Overall, 3,617 patients (5.5%) had at least 1 type of hospital-acquired infection (1,650 cases of urinary tract infection, 1,196 cases of pneumonia, 635 cases of surgical site infection, and 411 cases of bloodstream infection). The OR of hospital-acquired infection was highest for low eGFR (1.64; 95% CI, 1.51-1.77), followed by HF (1.60; 95% CI, 1.46-1.76), cerebrovascular disease (1.47; 95% CI, 1.34-1.61), cancer (1.43; 95% CI, 1.33-1.55), and COPD (1.37; 95% CI, 1.25-1.50). Low eGFR demonstrated the highest population-attributable fraction for hospital-acquired infections (0.13), followed by cancer (0.10), HF (0.09), and cerebrovascular disease (0.06). When assessed by type of infection, low eGFR particularly contributed to pneumonia (0.15) and urinary tract infection (0.10). LIMITATIONS Outcome ascertainment based on diagnostic codes. CONCLUSIONS These findings highlight the association between low eGFR and hospital-acquired infection and may inform evidence-based hospital-acquired infection prevention policies following major surgery.
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Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Helmen ZM, Helm MC, Helm JH, Nielsen A, Kindel T, Higgins R, Gould JC. Predictors of Postoperative Urinary Tract Infection After Bariatric Surgery. Obes Surg 2018; 28:1950-1954. [DOI: 10.1007/s11695-017-3095-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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