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Ashy CC, Morningstar JL, Gross CE, Scott DJ. The association of ASA score and outcomes following total ankle arthroplasty. Foot Ankle Surg 2024; 30:488-492. [PMID: 38594104 DOI: 10.1016/j.fas.2024.03.011] [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: 10/02/2023] [Revised: 02/16/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND This study seeks to evaluate the relationship between American Society of Anesthesiologist (ASA) score and postoperative outcomes following TAA. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007 to 2020 to identify 2210 TAA patients. Patients were stratified into low (n = 1328; healthy/mild systemic disease) or high (n = 881; severe/life-threatening systemic disease) ASA score cohorts. RESULTS There was no statistically significant difference in complications, readmission, or reoperation rate based on ASA score. Increased ASA score was significantly associated with longer length of stay (low = 1.69 days, high = 1.98 days; p < .001) and higher rate of adverse discharge (low = 95.3 %, high = 87.4 %; p < .001). CONCLUSION Higher ASA scores (3 and 4) were statically significantly associated with increased length of stay and non-home discharge disposition. These findings are valuable for physicians and patients to consider prior to TAA given the increased utilization of resources and cost associated with higher ASA scores. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Cody C Ashy
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Joshua L Morningstar
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Christopher E Gross
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Daniel J Scott
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
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2
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Akhtar M, Razick D, Mamidi D, Aamer S, Siddiqui F, Wen J, Shekhar S, Shekhar A, Lin JS. Complications, Readmissions, and Reoperations in Outpatient vs Inpatient Total Ankle Arthroplasty: A Systematic Review and Meta-analysis. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241264569. [PMID: 39070904 PMCID: PMC11282521 DOI: 10.1177/24730114241264569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
Background Total ankle arthroplasty (TAA) has primarily been performed in the inpatient setting. However, with the advent of fast-tracked joint arthroplasty protocols, TAA has slowly been shifting to the outpatient setting. Therefore, this systematic review aims to evaluate outcomes of outpatient TAA and compare them to inpatient TAA. Methods A literature search was performed on October 23, 2023, in the PubMed, Embase, and CENTRAL databases using the PRISMA guidelines. Studies were included if they reported on outcomes of outpatient TAA or compared outcomes between outpatient and inpatient TAA. Pooled odds ratios (ORs) and mean differences were calculated using a random effects model. Quality assessment was performed using the MINORS criteria. Results 12 studies were included, with 4 outpatient-only and 8 outpatient-inpatient comparative studies. Patients in the outpatient group were relatively younger, had a lower body mass index, and had fewer comorbidities relative to the inpatient group. For outpatient vs inpatient TAA, the pooled complication rate was 2.6% vs 3.6%, readmission rate was 2.5% vs 4%, and reoperation rate was 3.6% vs 5.5%. We found significantly lower odds of complications (OR = 0.47, CI: 0.26-0.85; P = .01), readmissions (OR = 0.63, CI: 0.54-0.74; P < .00001), and reoperations (OR = 0.66, CI: 0.46-0.95; P = .03) in the outpatient vs inpatient group. Conclusion Although this analysis is limited by the dominance of data included from a single study, we found that outpatient TAA was generally performed on lower-risk patients and was associated with lower rates of complications, readmissions, and reoperations compared with inpatient TAA.
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Affiliation(s)
- Muzammil Akhtar
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Daniel Razick
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Deeksha Mamidi
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Sonia Aamer
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Fayez Siddiqui
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Jimmy Wen
- College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Sakthi Shekhar
- Department of Orthopaedic Surgery, Good Samaritan Regional Medical Center, Corovalis, OR, USA
| | - Adithya Shekhar
- Department of Orthopaedic Surgery, Good Samaritan Regional Medical Center, Corovalis, OR, USA
| | - Jason S. Lin
- Department of Orthopaedic Surgery, Good Samaritan Regional Medical Center, Corovalis, OR, USA
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Wolfe I, Conti M, Henry J, Shaffrey I, Cororaton A, DiGiovanni G, Demetracopoulos C, Ellis S. Safety of Same-Day Discharge Following Total Ankle Arthroplasty: A Retrospective Cohort Analysis. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241241300. [PMID: 38577699 PMCID: PMC10989056 DOI: 10.1177/24730114241241300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Background Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the potential benefits of decreased health care expenses and improved patient satisfaction. Prior studies have not reliably made a distinction between outpatient TAA defined as length of stay <1 day and same-day discharge. The purpose of our study was to compare a large volume of same-day discharge and inpatient TAA for safety and efficacy. Methods Patients undergoing TAA at our US-based institution are part of an institutional review board-approved registry. We queried the registry for TAA performed by the single highest-volume surgeon at our institution between May 2020 and March 2022. Same-day discharge TAA was defined as discharge on the day of the procedure. Patient demographics, baseline clinical variables, concomitant procedures, postoperative complications, and patient-reported outcomes were collected. Postoperative outcomes were compared after 1:1 nearest-neighbor matching by age, sex, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) score. Multivariable models were created for comparison with the matched cohort outcome comparison analysis. Results Our same-day discharge group was younger (median 58 vs 67 years; P < .001), with proportionally fewer females (36.4% vs 51.4%; P = .044) and lower Charlson Comorbidity Indices (median 1 vs 3; P < .001) than the inpatient group. At a median follow-up of 1 year, after matching by age, sex, CCI, and ASA score, there was no difference in complications (P = .788), reoperations (P = .999), revisions (P = .118), or Patient-Reported Outcomes Measurement Information System (PROMIS) scores between the 2 groups. Multivariable analyses performed demonstrated no evidence of association between undergoing same-day discharge TAA vs inpatient TAA and reoperation, revision, complication, or 1-year PROMIS scores (P > .05). Conclusion In our system of health care, with appropriate patient selection, same-day discharge following TAA can be a safe alternative to inpatient TAA. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | | | | | | | | | | | | | - Scott Ellis
- Hospital for Special Surgery, New York, NY, USA
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Wolfe I, Demetracopoulos CA, Ellis SJ, Conti MS. Outpatient Total Ankle Arthroplasty (TAA) as a Rising Alternative to Inpatient TAA: A Database Analysis. Foot Ankle Int 2023; 44:1271-1277. [PMID: 37772875 DOI: 10.1177/10711007231199090] [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] [Indexed: 09/30/2023]
Abstract
BACKGROUND There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the benefit of decreased health care expenses and improved patient satisfaction. The purpose of our study was to compare readmissions, arthroplasty failures, infections, and annual trends between outpatient and inpatient TAA using a large publicly available for-fee database. METHODS The PearlDiver Database was queried to identify outpatient and inpatient TAA-associated claims for several payer types from January 2010 to October 2021. Preoperative patient characteristics and annual trends were compared for inpatient and outpatient TAA. International Classification of Diseases, Ninth and Tenth Revision, diagnosis codes were used to identify infections and arthroplasty failures. Complications rates were compared after matching patients by age, gender, and the following comorbidities: diabetes, smoking, congestive heart failure (CHF), hypertension (HTN), obesity, and chronic kidney disease (CKD). RESULTS A total of 12 274 patients were included in the final exact-matched analysis for complications, with 6137 patients in each group. Outpatients had a significantly lower rate of readmission within 90 days (2.6% vs 4.0%, P < .001), arthroplasty failure (4.1% vs 6.9%, P < .001), and infection (2.4% vs 3.1%, P = .015). Among database enrollees, outpatient TAA has risen in proportion to inpatient TAA from 2019 to 2021. CONCLUSION Outpatient TAA had lower rates of risk-adjusted readmission, arthroplasty failure, and infection compared to inpatient TAA. LEVEL OF EVIDENCE Level III, retrospective comparative database study.
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Affiliation(s)
- Isabel Wolfe
- Weill Cornell Medical College, New York, NY, USA
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Jennison T, Taher S, Ukoumunne O, Lamb S, Sharpe I, Goldberg A. Pulmonary Embolism, Mortality, and Medical Complications Following a Total Ankle Replacement: A Systematic Review and Meta-analysis. Foot Ankle Int 2023; 44:223-231. [PMID: 36779434 DOI: 10.1177/10711007221148164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND There is sparse data on the incidence of thromboembolic and medical complications following total ankle replacements. The aim of this systematic review was to determine the risk of deep vein thrombosis and pulmonary embolism as well as mortality and medical complications following ankle replacements. METHODS A systematic review was undertaken using all levels of evidence following PRISMA guidelines. Of the 1657 articles identified, 25 met the inclusion criteria. The inclusion criteria were a primary total ankle replacement with the recording of medical complications and/or thromboembolic events and/or mortality data. Two reviewers independently reviewed all articles. Quantitative methods were used to pool the percentages with complications across studies. RESULTS The pooled percentage with reported symptomatic deep vein thrombosis across 18 studies was 0.07% (95% CI 0.001%-0.59%). The pooled percentage with reported postoperative pulmonary embolism across 8 studies was 0.01% (95% CI 0.001%-0.03%). The pooled postoperative reported mortality was 0.06% (95% CI 0.001%-0.24%). Other medical complications had low incidences. CONCLUSION Our study indicates rates of reported thromboembolic events of less than 1 in 1000. Notably the level of evidence analyzed was mainly Level III and IV, likely underestimating the true incidence of these events because of recall and medical record limitations, and we had insufficient information on usage of chemoprophylaxis among these patients. LEVEL OF EVIDENCE Level IV, systematic review based on all levels of evidence including case series.
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Affiliation(s)
- Toby Jennison
- Royal Devon and Exeter NHS Trust, Exeter, United Kingdom.,University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Suhib Taher
- Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | | | - Sallie Lamb
- University of Exeter, Exeter, Devon, United Kingdom
| | - Ian Sharpe
- Royal Devon and Exeter NHS Trust, Exeter, United Kingdom
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Querci L, Caravelli S, Di Ponte M, Fuiano M, De Blasiis P, Sirico F, Baiardi A, Zannoni F, Mosca M. Enhanced recovery (fast-track surgery) after total ankle replacement: The state of the art. Foot Ankle Surg 2022; 28:1163-1169. [PMID: 35882574 DOI: 10.1016/j.fas.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/02/2022] [Accepted: 07/04/2022] [Indexed: 02/04/2023]
Abstract
The post-operative results of a total ankle replacement are not determined solely by an optimal surgical technique, but by an appropriate anesthesiological and rehabilitative post-operative approach. Enhanced functional recovery often depends on a multidisciplinary approach based on a correct framework of the patient and his needs, requests, and characteristics. Extensive bibliographical research has been performed on Pubmed, Google Scholar, Scopus. This comprehensive and inclusive review of the literature aims to examine the state of the art of "fast-track" protocols employed in total ankle replacement (TAR), considering pre-operative preparation, anesthetic management, intraoperative and surgical factors, post-operative rehabilitative care and reduction of hospitalization time.
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Affiliation(s)
- Lorenzo Querci
- Anesthesiology and Critical Care Residency Program, University of Bologna, Via Massarenti, 9, 40138 Bologna
| | - Silvio Caravelli
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Marco Di Ponte
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Mario Fuiano
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paolo De Blasiis
- Department of Mental and Physical Health and Preventive Medicine, Section of Human Anatomy, University of Campania"Luigi Vanvitelli", Naples, Italy
| | - Felice Sirico
- Department of Public Health - Physical Medicine & Rehabilitation Unit, Univeristy of Naples "Federico II", 80131 Naples, Italy
| | - Annalisa Baiardi
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Francesca Zannoni
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Massimiliano Mosca
- II Clinic of Orthopaedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Lima DJL, Sabesan VJ, Petersen-Fitts GR, Winkler ML, Sweet MC, Echeverry NB, Whaley JD. The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty. J Foot Ankle Surg 2022:S1067-2516(22)00330-1. [PMID: 36585326 DOI: 10.1053/j.jfas.2022.11.006] [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: 10/01/2018] [Revised: 10/21/2019] [Accepted: 11/13/2022] [Indexed: 11/29/2022]
Abstract
The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.
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Affiliation(s)
| | - Vani J Sabesan
- Cleveland Clinic Florida, Weston, FL; Wayne State University School of Medicine, Detroit, MI.
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8
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Karzon AL, Kadakia RJ, Coleman MM, Bariteau JT, Labib SA. The Rise of Total Ankle Arthroplasty Use: A Database Analysis Describing Case Volumes and Incidence Trends in the United States Between 2009 and 2019. Foot Ankle Int 2022; 43:1501-1510. [PMID: 36050924 DOI: 10.1177/10711007221119148] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide. METHODS The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA. RESULTS A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively. CONCLUSION We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty. LEVEL OF EVIDENCE Level III, retrospective database review.
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Affiliation(s)
- Anthony L Karzon
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rishin J Kadakia
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michelle M Coleman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sameh A Labib
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Systemic medical complications following total ankle arthroplasty: A review of the evidence. Foot Ankle Surg 2022; 28:804-808. [PMID: 34736847 DOI: 10.1016/j.fas.2021.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent. METHODS We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA. RESULTS The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration. CONCLUSIONS When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.
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10
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Total ankle replacement with INBONE-II prosthesis: A short-to-medium-term follow-up study in China. Chin Med J (Engl) 2022; 135:1459-1465. [PMID: 35853626 PMCID: PMC9481423 DOI: 10.1097/cm9.0000000000002192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Total ankle replacement (TAR) is a viable option for the treatment of end-stage ankle arthritis. In China, the INBONE-II implant is the only total ankle prosthesis approved since 2016. The purpose of this study is to report a large sample of findings for the TAR with INBONE-II prosthesis. METHODS A total of 65 patients with end-stage ankle arthritis, who underwent primary TAR using INBONE-II by the same surgeon from 2016 to 2019, at a single institution were included in this retrospective, single-center study. Clinical data, radiographic findings, survival rate, and complications were recorded and assessed pre-operatively and at the most recent follow-up. RESULTS A total of 64 patients were available for follow-up at least 2 years after surgery; the mean follow-up duration for clinical outcomes was 37.9 months (24-59 months), and for radiographic findings was 22.8 months (12-59 months). There were significant improvements (P < 0.01) in the American Orthopedic Foot and Ankle Society hindfoot scale, the visual analog scale for pain, and the Short Form-36. There were statistically significant differences between pre-operative and post-operative comparisons of the talar tilt angle (TT) and the tibial lateral surface angle (TLS) in the radiographic findings (TT from 4.7 ± 4.3° to 1.3 ± 1.3°, TLS from 80.4 ± 7.7° to 87.4 ± 2.3°, P < 0.01). There was no statistically significant difference in improvement of the tibial anterior surface angle (P = 0.14). Ten complications (all low grade) were recorded according to the Glazebrook classification system. The survivorship of the prosthesis was 100% (64/64). CONCLUSION Patients who underwent TAR with INBONE-II prosthesis demonstrated significant improvements in all measures of pain and function as well as in radiographic findings. High survival and a low incidence of complications were observed in this study.
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Mazzotti A, Viglione V, Gerardi S, Bonelli S, Zielli S, Geraci G, Faldini C. Post-operative management after total ankle arthroplasty: A systematic review of the literature. Foot Ankle Surg 2022; 28:535-542. [PMID: 34088605 DOI: 10.1016/j.fas.2021.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Currently, there is no consensus on the most appropriate post-operative management for patients undergoing total ankle arthroplasty. The aim of this study is therefore to offer a systematic review of the pertaining literature to identify current post-operative protocols and describe possible differences. METHODS A systematic review to identify recent studies concerning the post-operative management after total ankle arthroplasty was conducted. Five topics were analyzed: length of hospital stay, type and duration of immobilization, weight-bearing management, post-operative pharmacological therapies, adopted rehabilitation scheme. RESULTS Eighty-four studies met the inclusion criteria and were included in the review process. Most of the papers appear to have conflicting opinions with no consensus and homogeneous protocols. CONCLUSION Due to various methodological limitations, it is not possible to provide sufficiently supported evidence-based recommendations, and it is therefore difficult to determine the superiority of one post-operative protocol over the others after total ankle arthroplasty.
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Affiliation(s)
- A Mazzotti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
| | - V Viglione
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - S Gerardi
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - S Bonelli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - S Zielli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - G Geraci
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - C Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123, Bologna, Italy
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12
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Turcotte J, Spirt A, Keblish D, Holt E. Total Ankle Arthroplasty Can Be Safely and Effectively Performed in the Community Hospital Setting: A Case Series of 65 Patients. J Foot Ankle Surg 2022; 61:827-830. [PMID: 34974983 DOI: 10.1053/j.jfas.2021.11.026] [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: 04/08/2020] [Revised: 07/20/2020] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
The use of total ankle arthroplasty has expanded over the past decade, primarily due to improvements in implant design and survivorship that have significantly reduced the high failure rates observed in first-generation implants. A retrospective review of 65 consecutive patients undergoing primary total ankle arthroplasty with a single senior orthopedic surgeon in a community hospital from January 2014 to December 2019 was performed. All procedures were performed for end stage osteoarthritis, with the most common secondary diagnoses being Achilles contracture (23%), retained hardware (17%) and calcaneovalgus deformity (11%). Preoperatively, patients averaged 10.45 ̊ ± 10.00 ̊ of non-weightbearing dorsiflexion and 30.00 ̊ ± 8.79 ̊ of plantarflexion. Postoperatively, patients averaged 13.33 ̊ ± 7.62 ̊ dorsiflexion, and 25.48 ̊ ± 7.87 ̊ of plantarflexion. A total of 8 (12.3%) patients required reoperation, and average time to reoperation was 1.55 ± 1.58 years. Implant failure, defined as reoperation requiring prosthesis removal, occurred in 2 (3.1%) patients, with an average time to failure of 342 days (105 days in failure due to periprosthetic joint infection and 582 days in failure due to subsidence). Patients undergoing total ankle arthroplasty at our institution had a 12.3% reoperation rate, and a 96.9% implant survival rate over an average follow-up period of 2.42 years, results that compare favorably with previously reported outcomes. Based on these findings, we suggest that this procedure, which is often offered only in academic tertiary care facilities, can be safely and effectively performed by experienced surgeons in the community hospital setting.
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Affiliation(s)
- Justin Turcotte
- Director, Orthopedic and Surgery Research, Anne Arundel Medical Center Orthopedics, Annapolis, MD.
| | - Adrienne Spirt
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
| | - David Keblish
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
| | - Edward Holt
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
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Del Balso C, Halai MM, MacLeod MD, Sanders DW, Rahman Lawendy A. Factors Predictive of Early Complications Following Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221102456. [PMID: 35722173 PMCID: PMC9201329 DOI: 10.1177/24730114221102456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: The safety of outpatient total ankle arthroplasty (TAA), and factors
predictive of early complications are poorly understood. The objective of
this study was to determine the frequency of early complications in patients
undergoing outpatient TAA compared to a matched inpatient TAA cohort.
Factors predictive of early complications following TAA are elucidated. Methods: A retrospective review of prospectively collected data from the 2011-2018
American College of Surgeons–National Surgical Quality Improvement Program
(ACS-NSQIP) database was performed. An unadjusted analysis comparing
complication rates in outpatient, and inpatient TAA was performed followed
by a propensity score–matched cohort analysis. A multivariate logistic
regression model was then used to identify significant independent
predictors for complications, reoperation, and readmission following
TAA. Results: A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were
included in the study. Inpatient TAA was associated with increased 30-day
readmission compared with outpatient TAA (3.54% vs 0.51%, P
= .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a
minor complication, with 16 (1.1%) patients having a major complication
after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%)
patients were readmitted within 30 days of the index TAR. Multivariate
analysis identified factors predictive of early complications to include
length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders,
and diabetes mellitus. Conclusion: From this relatively limited data set, outpatient TAA appears to be safe for
management of end-stage ankle arthritis in select patients. Inpatient status
was associated with an increased rate of 30-day readmission following TAA.
Postoperative length of stay >2 days, smoking, hypertension, bleeding
disorders, and diabetes mellitus were identified to be associated with early
postoperative complications following TAA in this cohort. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Christopher Del Balso
- Department of Surgery, Division of
Orthopaedic Surgery, London Health Sciences Centre–Victoria Hospital, Western
University, London, Ontario, Canada
- Christopher Del Balso, MBBS, MSc,
Department of Surgery, Division of Orthopaedic Surgery, London Health Sciences
Centre – Victoria Hospital, Western University, 800 Commissioners Rd E, London,
ON N6A 5W9, Canada.
| | - Mansur M. Halai
- Department of Surgery, Division of
Orthopaedic Surgery, St. Michael’s Hospital, University of Toronto, Toronto,
Ontario, Canada
| | - Mark D. MacLeod
- Department of Surgery, Division of
Orthopaedic Surgery, London Health Sciences Centre–Victoria Hospital, Western
University, London, Ontario, Canada
| | - David W. Sanders
- Department of Surgery, Division of
Orthopaedic Surgery, London Health Sciences Centre–Victoria Hospital, Western
University, London, Ontario, Canada
| | - Abdel Rahman Lawendy
- Department of Surgery, Division of
Orthopaedic Surgery, London Health Sciences Centre–Victoria Hospital, Western
University, London, Ontario, Canada
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Kayum S, Kooner S, Khan RM, Halai M, Awoke A, Kanani A, Montgomery S, Meldrum A, Daniels TR. Safety and Effectiveness of Outpatient Total Ankle Arthroplasty. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211057888. [PMID: 35097480 PMCID: PMC8646201 DOI: 10.1177/24730114211057888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA. METHODS This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results. RESULTS In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA. CONCLUSIONS The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.Level of Evidence: Level IV, case series.
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Affiliation(s)
- Shahin Kayum
- Unity Health Toronto–St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Sahil Kooner
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ryan M. Khan
- Unity Health Toronto–St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Mansur Halai
- Unity Health Toronto–St. Michael’s Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Adam Awoke
- St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Asa Kanani
- St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Spencer Montgomery
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Timothy R. Daniels
- University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada
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15
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Sadoun M, Hardy A, Cladière V, Guichard L, Bauer T, Stiglitz Y. Outpatient total ankle replacement. INTERNATIONAL ORTHOPAEDICS 2021; 45:2429-2433. [PMID: 34274986 DOI: 10.1007/s00264-021-05140-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Since the development of the last generation of implants total ankle replacements (TAR) is becoming more and more popular in patients and in specialized surgeon teams, the trend for outpatient surgery is growing, and protocols now are well established for hip or knee replacement. We adapted a protocol for outpatient TAR and hypothesized that it could be performed safely as standard procedure. PATIENTS AND METHODS Twenty-five consecutive patients among 141 TAR were treated with our outpatient protocol relying on three fundamentals: bleed control, pain control, and autonomy. They received 1 g of tranexamic acid before surgery, and after discard from post-operative care unit, they were operated under long-lasting nerve block precociously relayed by oral NSAIDs and had an immediate full weight-bearing authorization at discharge. RESULTS No patients we readmitted for an acute care following TAR, especially for haematoma or uncontrolled pain. Mean VAS was < 1 before discharge from post-operative care unit and < 2 until day 90. One patient had a delayed wound healing treated surgically at day 30 without implant revision. CONCLUSION Outpatient TAR is possible and safe if a risk management process is used, and the three basic principles for outpatient procedures are respected: bleed control, pain control, and patient autonomy. We consider now this modality as a routine.
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Affiliation(s)
- Maxime Sadoun
- Department of Orthopedics, Ambroise Paré University Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, 9 Avenue Charles de Gaulle, 92100, Boulogne-Billancourt, Paris, France
| | - Alexandre Hardy
- Clinique du Sport, Paris 5, 36 boulevard Saint-Marcel, 75005, Paris, France
| | - Victoire Cladière
- Department of Orthopedics, Cochin University Hospital, APHP, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Leah Guichard
- Department of Anesthesiology, Raymond Poincaré Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, 104 Boulevard Raymond Poincaré, 92380, Garches, Paris, France
| | - Thomas Bauer
- Department of Orthopedics, Ambroise Paré University Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, 9 Avenue Charles de Gaulle, 92100, Boulogne-Billancourt, Paris, France
| | - Yves Stiglitz
- Clinique Victor Hugo, 5 rue du Dôme, 75116, Paris, France.
- Department of Orthopaedics, Raymond Poincaré Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, 104 Boulevard Raymond Poincaré, 92380, Garches, Paris, France.
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16
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Berlet GC, Brandão RA, Consul D, Ebaugh P, Hyer CF. Short- to Midterm Follow-up of Cemented Total Ankle Replacement Using the INBONE II: A Retrospective Chart Review. Foot Ankle Spec 2021; 14:302-311. [PMID: 32312108 DOI: 10.1177/1938640020913126] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Total ankle arthroplasty is a viable option for the treatment of end stage ankle arthritis. The purpose of this study is to report on the mid-term results with a cemented total ankle prosthesis, the Inbone™ II implant over a 5 year period. Methods: A retrospective, single-center chart and radiographic review of all patients with end stage ankle arthritis treated with Inbone™ II TAR) as the primary index procedure from 12/1/2012 to 3/1/2017. Clinical data were evaluated at 3 month, 6 month, 1 year and subsequent intervals for the study period. Preoperative diagnosis, pertinent patient demographics adjunctive procedures, implant associated complications, subsequent surgeries, and revisions were recorded. Results: 121 total ankles met our inclusion criteria. Patients had an INBONE™ II TAR implant placed with bone cement with a minimum of a 12 months follow up. Average age was 62.88 (range, 32-87) years, average body mass index was 32.74 (range, 21.8-56.04) kg/m2 and average follow up was 28.51(range, 12-69) months. Using the COFAS complication classification there were 14 minor, 11 moderate, and 5 major complications. 6/121 (5.0%) revisions which included: polyethylene exchange, device explant/fusion, and antibiotic spacer in situ. No complications over the course of this study ended in amputation. Conclusion: Total Ankle Arthroplasty utilizing the cemented INBONE™ II yielded good midterm results with regards to minor, moderate, and major complications. Rate of revision 6/121 (5.0%) was within the reported range with only 5 patients converted to fusion during the study period resulting in a 95% survivability at mid-term follow up.Levels of Evidence: Level IV: Retrospective case series.
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Affiliation(s)
- Gregory C Berlet
- Orthopedic Foot and Ankle Center, Worthington, Ohio (GCB, CFH).,The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, Maryland (RAB).,OhioHealth, Grant Medical Center, Ohio (DC, PE)
| | - Roberto A Brandão
- Orthopedic Foot and Ankle Center, Worthington, Ohio (GCB, CFH).,The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, Maryland (RAB).,OhioHealth, Grant Medical Center, Ohio (DC, PE)
| | - Devon Consul
- Orthopedic Foot and Ankle Center, Worthington, Ohio (GCB, CFH).,The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, Maryland (RAB).,OhioHealth, Grant Medical Center, Ohio (DC, PE)
| | - Pierce Ebaugh
- Orthopedic Foot and Ankle Center, Worthington, Ohio (GCB, CFH).,The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, Maryland (RAB).,OhioHealth, Grant Medical Center, Ohio (DC, PE)
| | - Christopher F Hyer
- Orthopedic Foot and Ankle Center, Worthington, Ohio (GCB, CFH).,The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, Maryland (RAB).,OhioHealth, Grant Medical Center, Ohio (DC, PE)
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17
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Albright RH, Rodela RJ, Nabili P, Gentchos CE, Summers NJ. Complication Rates Following Total Ankle Arthroplasty in Inpatient versus Outpatient Populations: A Systematic Review & Meta-Analysis. J Foot Ankle Surg 2021; 60:61-66. [PMID: 33218868 DOI: 10.1053/j.jfas.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/08/2020] [Indexed: 02/03/2023]
Abstract
Total ankle arthroplasty (TAA) is used as an alternative to ankle arthrodesis for adults with severe ankle arthritis. Numerous orthopedic centers have entered the healthcare market offering fast-tracked joint replacement protocols, meanwhile, TAA has been excluded from these joint centers, and is primarily performed in the inpatient setting. The purpose of this study is to examine short-term complications in the inpatient and outpatient settings following TAA using a systematic review and quantitative analysis. We considered all studies examining short-term complications following TAA performed in the inpatient versus outpatient setting occuring within 1 year of the index operation. We summarized data using a pooled relative risk and random effects model. A pooled sensitivity analysis was performed for studies with data on complication rates for inpatient or outpatient populations, which did not have a control group. The quality of included studies was assessed using the Cochrane risk of bias tool. Nine studies were included in the quantitative analysis, with 4 studies in the final meta-analysis. Subjects undergoing inpatient surgery experienced a 5-times higher risk of short-term complications compared to the outpatient group (risk ratio 5.27, 95% confidence interval 3.31, 8.42). Results did not change after sensitivity analysis (inpatient weighted mean complication rate: 9.62% vs outpatient weighted mean 5.02%, p value <.001). The overall level of evidence of included studies was level III, with a moderate to high risk of bias. Outpatient TAAs do not appear to pose excess complication risks compared to inpatient procedures, and may therefore be a reasonable addition to experienced centers that have established a fast-track outpatient total joint protocol.
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Affiliation(s)
- Rachel H Albright
- Fellow, The Dartmouth Institute for Clinical Practice & Health Policy, Geisel School of Medicine, Hanover, NH.
| | - Ryan J Rodela
- Resident, Department of Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL
| | - Panah Nabili
- Resident, Department of Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL
| | - Chris E Gentchos
- Foot & Ankle Orthopaedic Surgeon, Concord Orthopaedics, Concord, NH
| | - N Jake Summers
- Foot & Ankle Podiatric Surgeon, Department of Orthopaedics, Dartmouth-Hitchcock Manchester, Manchester, NH
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18
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Jantzen C, Ebskov LB, Andersen KH, Benyahia M, Rasmussen PB, Johansen JK. Overnight Admission After Total Ankle Replacement: Is It Safe? J Foot Ankle Surg 2021; 60:89-92. [PMID: 33187900 DOI: 10.1053/j.jfas.2020.08.032] [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: 07/10/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 02/03/2023]
Abstract
To evaluate readmission, complication, and nonscheduled contact rates to the out-patient clinic within the first 3 months following total ankle replacement in patients planned for overnight admission. Data were collected retrospectively on all patients treated during the period the December 11, 2015 to the December 1, 2019 with 3 months of follow-up for all patients. In the study 116 patients were included. No difference in patient characteristics, readmission rates, complication rates or number of nonscheduled contacts to the outpatient clinic was found between patients discharged after 1 day when compared to those admitted >1 day. Around 58.6% was discharged as planned. The overall readmission and complication rates were 2.6% and 6.0% respectively, 20.7% had a nonscheduled contact to the out-patient clinic. No differences in prevalence of the different complications, reasons for readmission or reasons for contact to the out-patient clinic were found between overnight admission and inpatient admission. Total ankle placement with overnight admission is safe, but patient selection with a thorough plan for analgesics after discharge and optimal cast appliance is necessary.
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Affiliation(s)
- Christopher Jantzen
- Senior Resident, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark.
| | - Lars Bo Ebskov
- Chief Physician and Foot and Ankle Surgeon, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Kim Hegnet Andersen
- Chief Physician and Foot and Ankle Surgeon, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Mostafa Benyahia
- Chief Physician and Foot and Ankle Surgeon, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Peter Bro Rasmussen
- Chief Physician and Foot and Ankle Surgeon, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Jens Kurt Johansen
- Chief Physician and Foot and Ankle Surgeon, Department of Orthopedic Surgery, Foot and Ankle Division, Hvidovre University Hospital, Copenhagen, Denmark
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19
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Khazi ZM, Lu Y, Cregar W, Shamrock AG, Gulbrandsen TR, Mascarenhas R, Forsythe B. Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis. Arthroscopy 2021; 37:42-49. [PMID: 32721541 DOI: 10.1016/j.arthro.2020.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- Zain M Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A..
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - William Cregar
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Alan G Shamrock
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
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20
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Akoh CC, Fletcher AN, Chen J, Wang J, Adams SA, DeOrio JK, Nunley JA, Easley ME. Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery. Foot Ankle Int 2021; 42:96-106. [PMID: 32875812 DOI: 10.1177/1071100720949200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). METHODS We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. RESULTS The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001). CONCLUSION While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Craig C Akoh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Juanto Wang
- Department of Foot and Ankle Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Samuel A Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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21
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Lu Y, Lavoie-Gagne O, Khazi Z, Patel BH, Mascarenhas R, Forsythe B. Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications. Knee Surg Sports Traumatol Arthrosc 2020; 28:2486-2493. [PMID: 32719934 DOI: 10.1007/s00167-020-06094-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. METHODS The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05. RESULTS From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001). CONCLUSIONS Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yining Lu
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ophelie Lavoie-Gagne
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Zain Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bhavik H Patel
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Randhir Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA.
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22
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Plantz MA, Sherman AE, Kadakia AR. A propensity score-matched analysis comparing outpatient and short-stay hospitalization to standard inpatient hospitalization following total ankle arthroplasty. J Orthop Surg Res 2020; 15:292. [PMID: 32736627 PMCID: PMC7394689 DOI: 10.1186/s13018-020-01793-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Background Given the trend toward value-based care, there has been increased interest in minimizing hospital length of stay (LOS) after orthopedic procedures. Outpatient total ankle arthroplasty (TAA) has become more popular in recent years; however, research on surgical outcomes of this procedure has been limited. This study sought to employ large sample, propensity score-matched analyses to assess the safety of outpatient and short-stay discharge pathways following TAA. Methods The ACS NSQIP database was used to identify 1141 patients who underwent primary and revision TAA between 2007 and 2017. Propensity score matching was used to match patients based on several factors, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and several comorbidities. The incidence of various 30-day complications was compared between the short and standard LOS groups to assess for any differences in short-term outcomes. Results A total of 892 patients were included in the final propensity score-matched analysis, with 446 patients in each group. The short LOS group had a significantly lower rate of medical complications (0.2% vs. 2.5%, p = 0.006) and non-home discharge (1.3% vs. 12.1%, p < 0.001). There was no significant difference in operative complications (0.4% vs. 1.8%, p = 0.107), unplanned readmission (0.4% vs. 1.1%, p = 0.451), reoperation (0.2% vs. 0.4%, p > 0.999), return to the OR (0.2% vs. 0.9%, p = 0.374), or mortality (0.7% vs. 0.0%, p > 0.249) between the short and standard LOS groups. Conclusions Outpatient and short-stay hospitalization had comparable safety to standard inpatient hospitalization after TAA. Outpatient or short-stay TAA should be considered for patients with low risk of short-term complications.
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Affiliation(s)
- Mark A Plantz
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 1350, Chicago, Cook County, IL, 60611, USA.
| | - Alain E Sherman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 1350, Chicago, Cook County, IL, 60611, USA.,Kellogg School of Management at Northwestern University, 2211 Campus Drive, Evanston, Cook County, IL, 60208, USA
| | - Anish R Kadakia
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 1350, Chicago, Cook County, IL, 60611, USA
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Lai WC, Arshi A, Ghorbanifarajzadeh A, Williams JR, Soohoo NF. Incidence and predictors of early complications following primary and revision total ankle arthroplasty. Foot Ankle Surg 2019; 25:785-789. [PMID: 30467054 DOI: 10.1016/j.fas.2018.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/25/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers. METHODS A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs. RESULTS The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis. CONCLUSIONS Older age, higher BMI, and revision cases are associated with a higher risk of AEs.
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Affiliation(s)
- Wilson C Lai
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA 76-143 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, United States.
| | - Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA 76-143 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, United States.
| | - Ali Ghorbanifarajzadeh
- University Foot & Ankle Institute, 1245 Wilshire Blvd Ste 306, Los Angeles, CA, 90017, United States.
| | - Joan R Williams
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA 76-143 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, United States.
| | - Nelson F Soohoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA 76-143 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, United States.
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Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement. PURPOSE To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery. METHODS Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken. RESULTS Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management. CONCLUSIONS Future research is now required for ERAS procedure-specific components for TSR surgery.
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Wainwright TW, Immins T, Antonis JHA, Taylor H, Middleton RG. Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery? Foot Ankle Surg 2019; 25:294-297. [PMID: 29409177 DOI: 10.1016/j.fas.2017.12.005] [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: 09/06/2017] [Revised: 11/10/2017] [Accepted: 12/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been successfully adopted across a range of procedures. This study explores whether there is scope to improve length of stay (LOS) for total ankle replacement surgery (TAR) in the UK by implementing ERAS pathways. METHODS Hospital Episode Statistics (HES) data (April 2015/March 2016) on LOS for TAR were analysed. A literature search was then carried out to examine whether there were any publications on outpatient TAR and/or the use of ERAS protocols. RESULTS Mean observed LOS was 3.3days (range 0-17.3) days. Case mix-adjusted expected LOS range was 2.0-5.7 days. It is likely that the wide observed LOS range is due to differences in local processes and pathways. Two papers were found by the literature search. CONCLUSIONS TAR should aim to be outpatient surgery as the literature, and data demonstrating scope for improvement in LOS, suggest this should be possible.
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Affiliation(s)
- Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, 6th Floor, Executive Business Centre, 89 Holdenhurst Road, Bournemouth, BH8 8EB, UK; Orthopaedic Department, The Royal Bournemouth Hospital, Castle Lane, Bournemouth, BH7 7DW, UK.
| | - Tikki Immins
- Orthopaedic Research Institute, Bournemouth University, 6th Floor, Executive Business Centre, 89 Holdenhurst Road, Bournemouth, BH8 8EB, UK.
| | - Johannes H A Antonis
- Orthopaedic Research Institute, Bournemouth University, 6th Floor, Executive Business Centre, 89 Holdenhurst Road, Bournemouth, BH8 8EB, UK; Orthopaedic Department, The Royal Bournemouth Hospital, Castle Lane, Bournemouth, BH7 7DW, UK.
| | - Heath Taylor
- Orthopaedic Department, The Royal Bournemouth Hospital, Castle Lane, Bournemouth, BH7 7DW, UK.
| | - Robert G Middleton
- Orthopaedic Research Institute, Bournemouth University, 6th Floor, Executive Business Centre, 89 Holdenhurst Road, Bournemouth, BH8 8EB, UK; Orthopaedic Department, The Royal Bournemouth Hospital, Castle Lane, Bournemouth, BH7 7DW, UK.
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Huntley SR, McGee AS, Johnson JL, Debell HA, McKissack HM, McGwin G, Naranje SM, Shah A. Outcomes of Inpatient Versus Outpatient Elective Foot and Ankle Surgery. Cureus 2019; 11:e4058. [PMID: 31016085 PMCID: PMC6464278 DOI: 10.7759/cureus.4058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Complications following orthopedic surgeries are undesirable and costly. A potential method to reduce these costs is to perform traditionally inpatient surgical procedures in the outpatient setting. The purpose of this study is to compare outcomes between inpatient and outpatient settings for elective foot and ankle surgeries using the National Surgical Quality Improvement Program (NSQIP) database. Methods Patients with Current Procedural Terminology (CPT) codes specific to orthopedic foot and ankle surgery were identified from the 2011-2015 American College of Surgeons NSQIP database. Demographics, comorbidities, and complications were compared between patients undergoing inpatient and outpatient procedures. Results Patients receiving inpatient surgery were significantly older and more frequently male. Black patients were significantly more likely to undergo inpatient surgery than outpatient surgery while white patients were significantly more likely to undergo outpatient surgery. Outpatients had a significantly higher mean body mass index (BMI) than inpatients. Smokers were at a significantly greater risk of undergoing inpatient surgery than outpatient surgery. Outpatients had significantly longer operative times, were more likely to receive general anesthesia, had a lower American Society of Anesthesiologists (ASA) class, were more likely to be functionally independent, and were less likely to expire postoperatively. Patients who received surgery as an inpatient were significantly more likely to have comorbidities as compared to outpatients. The overall risk of surgical complications was significant between groups with 8.6% in the inpatient group and 2.0% in the outpatient group. The overall risk of medical complications was 16.9% in the inpatient group and 1.7% in the outpatient group. Similar to the surgical complications, inpatients were significantly more likely to sustain each of the individual medical complications except for stroke/CVA and venous thromboembolism. Conclusions Outpatient management is associated with decreased postoperative complications in select patients. Performing more operations in the outpatient setting in select patients may be beneficial for cost reduction and patient satisfaction.
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Affiliation(s)
- Samuel R Huntley
- Miscellaneous, Miller School of Medicine, University of Miami, Miami, USA
| | - Andrew S McGee
- Orthopaedics, University of Alabama School of Medicine, Birmingham, USA
| | - John L Johnson
- Miscellaneous, University of Alabama School of Medicine, Birmingham, USA
| | - Henry A Debell
- Orthopaedics, University of Alabama School of Medicine, Birmingham, USA
| | - Haley M McKissack
- Orthopaedics, University of Alabama School of Medicine, Birmingham, USA
| | - Gerald McGwin
- Epidemiology, University of Alabama School of Medicine, Birmingham, USA
| | - Sameer M Naranje
- Orthopaedics, University of Alabama School of Medicine, Birmingham, USA
| | - Ashish Shah
- Orthopaedics, University of Alabama School of Medicine, Birmingham, USA
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Patient and Practice Trends in Total Ankle Replacement and Tibiotalar Arthrodesis in the United States From 2007 to 2013. J Am Acad Orthop Surg 2019; 27:e77-e84. [PMID: 30169446 DOI: 10.5435/jaaos-d-17-00526] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Both total ankle replacement (TAR) and tibiotalar arthrodesis (TTA) are used in the surgical management of ankle arthritis. Over the past decade, TAR instrumentation, techniques, and implants have improved, making the procedure more reliable and reproducible, thus making TAR more common. METHODS The Nationwide Inpatient Sample database from 2007 to 2013 was used to obtain data on patients elder than 50 years who underwent either TAR or TTA. Differences in temporal, demographic, and diagnosis trends between TAR and TTA were analyzed. RESULTS Between 2007 and 2013, 15,060 patients underwent TAR and 35,096 underwent TTA. Patients undergoing TTA had significantly more comorbidities (2.17 versus 1.55; P < 0.001). The share of TAR performed increased significantly from 2007 (14%) to 2013 (45%) (P < 0.001). From 2007 to 2013, we found a 12-fold increase in the odds of having a TAR for patients with posttraumatic osteoarthritis (P < 0.001), a 4.9-fold increase for those with primary osteoarthritis, and a 3.1-fold increase for patients with rheumatoid arthritis (P < 0.001). CONCLUSIONS Over the past decade, the frequency of TAR has increased, particularly in patients with posttraumatic arthritis and osteoarthritis. Surgeons still perform TAR in healthier patients compared with TTA; however, because surgeons become more experienced with the technique, patients are undergoing TAR at a markedly higher rate. LEVEL OF EVIDENCE Level III: retrospective comparative study.
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Tedder C, DeBell H, Dix D, Smith WR, McGwin G, Shah A, Naranje S. Comparative Analysis of Short-Term Postoperative Complications in Outpatient Versus Inpatient Total Ankle Arthroplasty: A Database Study. J Foot Ankle Surg 2019; 58:23-26. [PMID: 30316642 DOI: 10.1053/j.jfas.2018.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Indexed: 02/06/2023]
Abstract
Ankle arthritis is a potentially debilitating disease, with approximately 50,000 cases diagnosed annually. One treatment option for these patients is total ankle arthroplasty (TAA). This procedure has historically been performed in the inpatient setting with a 1-2-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore it is important to evaluate the safety of specific procedures in the outpatient setting compared with the inpatient setting. This study evaluated the complication rates in inpatient versus outpatient TAA. It analyzed data from the National Surgical Quality Improvement Program for 591 patients who received TAA. Postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. Unadjusted direct comparisons of the cohorts revealed higher complication rates in the inpatient cohort. Inpatients had higher rates of superficial surgical site infections, deep surgical site infections, number of organ/space surgical site infections, pneumonia occurrences, and return to the operating room, but these differences were not significant. These results showed no significant increase in complication rates in outpatients compared to inpatients. Our results suggest that inpatient and outpatient TAA show similar complication rates. This suggests that outpatient TAA is safe and may be a superior option for certain populations. Further investigation is warranted to verify these conclusions.
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Affiliation(s)
- Chandler Tedder
- Medical Student, University of South Alabama College of Medicine, Mobile, AL
| | - Henry DeBell
- Medical Student, University of Alabama School of Medicine, Birmingham, AL
| | - Daniel Dix
- Medical Student, University of Alabama School of Medicine, Birmingham, AL
| | - Walter R Smith
- Medical Student, University of Alabama School of Medicine, Birmingham, AL
| | - Gerald McGwin
- Professor and Vice Chairman, Department of Epidemiology, School of Public Health, University of Alabama School of Medicine, Birmingham, AL
| | - Ashish Shah
- Assistant Professor, Department of Orthopaedic Surgery, University of Alabama School of Medicine, Birmingham, AL.
| | - Sameer Naranje
- Assistant Professor, Department of Orthopaedic Surgery, University of Alabama School of Medicine, Birmingham, AL
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Taylor MA, Parekh SG. Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management. Orthop Clin North Am 2018; 49:541-551. [PMID: 30224015 DOI: 10.1016/j.ocl.2018.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.
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Affiliation(s)
- Michel A Taylor
- Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA; Duke Fuqua School of Business, 100 Fuqua Drive, Durham, NC 27708, USA; North Carolina Orthopedic Clinic, 3609 Southwest Durham Drive, Durham, NC 27707, USA.
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Gupta A, Kumar K, Roberts MM, Sanders AE, Jones MT, Levine DS, O'Malley MJ, Drakos MC, Elliott AJ, Deland JT, Ellis SJ. Pain Management After Outpatient Foot and Ankle Surgery. Foot Ankle Int 2018; 39:149-154. [PMID: 29078056 DOI: 10.1177/1071100717738495] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia. METHODS Eighty-four patients underwent outpatient foot and ankle surgeries under spinal blockade and long-acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3-day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids. RESULTS Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication. CONCLUSIONS Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Akash Gupta
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Kanupriya Kumar
- 2 Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Matthew M Roberts
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Austin E Sanders
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mackenzie T Jones
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David S Levine
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Martin J O'Malley
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mark C Drakos
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Andrew J Elliott
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan T Deland
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Scott J Ellis
- 1 Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
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Borenstein TR, Anand K, Li Q, Charlton TP, Thordarson DB. A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty. Foot Ankle Int 2018; 39:143-148. [PMID: 29160727 DOI: 10.1177/1071100717738748] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. METHODS The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). RESULTS There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. CONCLUSION This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Todd R Borenstein
- 1 Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kapil Anand
- 2 Department of Anesthesiology, Regional Anesthesia/Acute Pain Fellowship Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Quanlin Li
- 3 Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy P Charlton
- 1 Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David B Thordarson
- 1 Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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