Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery

Resection Outcomes of Posttraumatic Elbow Heterotopic Ossification: Multicenter Case Series at a Minimum 5-Year Follow-Up

BACKGROUND

Heterotopic ossification (HO), a common complication after elbow trauma, causes severe limb disability. Resection is usually performed for posttraumatic elbow HO (PTEHO) to regain mobility, and although heavily reported, there has been no long-term (minimum, 5-year) follow-up.

METHODS

A total of 173 patients who underwent PTEHO resection were followed up for a minimum of 5 years in 4 hospitals between January of 2015 and August of 2016. Demographics, disease characteristics, and preoperative and minimum 5-year assessments were collected. After controlling for potential variables when dividing long-term range of motion (ROM) into less than 120 degrees and greater than or equal to 120 degrees, risk factors for ROM recovery to modern functional arc were identified through multivariable regression analysis.

RESULTS

Clinically important improvements in ROM from 39 degrees to 124 degrees were obtained at final follow-up, and 74.6% achieved modern functional arc (≥120 degrees). Mayo Elbow Performance Index had clinically important increases from 69 to 93 points at final follow-up, and 96.5% reported excellent to good. Pain (numeric rating scale, from 1.9 to 0.6 points) and ulnar nerve symptoms were improved. The total complication rate was 15.6%, including new-onset ulnar nerve symptoms (5.8%), HO recurrence with clinical symptoms (6.9%), elbow instability (1.7%), and joint infection (1.2%). Previously reported high body mass index ( P = 0.002) and long disease duration ( P = 0.033) were equally identified as risk factors for not achieving modern functional arc; meanwhile, tobacco use ( P = 0.024) and ankylosed HO ( P < 0.001) were found to be new risk factors.

CONCLUSIONS

Resection yields satisfactory outcomes for PTEHO at long-term follow-up of a minimum of 5 years. High body mass index, tobacco use, long disease duration, and ankylosed HO would negatively affect ROM recovery to a modern functional arc (≥120 degrees).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The Effect of Implementing a Standardized Enhanced Recovery After Surgery Pain Management Pathway at an Urban Medical Center in Hawaii

Traditional use of opioids to treat postoperative pain may lead to abuse and overdose. The development of Enhanced Recovery After Surgery (ERAS) protocols has helped to shift pain management from traditional methods to evidence-based best practices involving multimodal analgesia techniques. The purpose of this quality improvement project was to implement and determine the effectiveness of a standardized, evidence-based ERAS pain management pathway for patients undergoing colorectal or gynecology procedures at a medical center in Hawaii. After the intervention, the evaluation of data associated with opioid use, patients' pain scores, time spent in the postanesthesia care unit, and inpatient length of stay showed that most results were not significant. However, the ERAS pain management pathway did reduce clinical practice variations, intraoperative opioid administration, the time that patients spent in the postanesthesia care unit, and length of stay. The ERAS pain management pathway continues to be used and updated at this facility.

Supra-inguinal fascia iliaca block in older-old patients for hip fractures: a retrospective study

BACKGROUND

Pain management in hip fracture patients is of great importance for reducing postoperative morbidity and mortality. Multimodal techniques, including peripheral nerve blocks, are preferred for postoperative analgesia. Older-old hip fracture patients with high ASA scores are highly sensitive to the side effects of NSAIDs and opioids. Our aim was to investigate the effectiveness of the recently popularized Supra-Inguinal Fascia Iliaca Block (SIFIB) in this population.

METHODS

Forty-one ASA III...IV patients who underwent SIFIB...+...PCA (G-SIFIB) or PCA alone (Group Control: GC) after general anesthesia were evaluated retrospectively. In addition to 24-hour opioid consumption, Visual Analog Scale (VAS) scores, opioid-related side effects, block-related complications, and length of hospital stay were compared.

RESULTS

Twenty-two patients in G-SIFIB and 19 patients in GC were evaluated. The postoperative 24-hour opioid consumption was lower in G-SIFIB than in GC (p...<...0.001). There was a statistically significant reduction in VAS scores at the postoperative 1st, 3rd, and 6th hours at rest (p...<...0.001) and during movement (p...<...0.001 for the 1st and 3rd hours, and p...=...0.02 for the 6th hour) in G-SIFIB compared to GC. There was no difference in pain scores at the 12th and 24th hours postoperatively. While there was no difference between the groups in terms of other side effects, respiratory depression was significantly higher in GC than in G-SIFIB (p...=...0.01).

CONCLUSION

The SIFIB technique has a significant opioid-sparing effect and thus reduces opioid-related side effects in the first 24 hours after hip fracture surgery in older-old patients.

Early perioperative quality of recovery after hip and knee arthroplasty: a retrospective comparative cohort study

PURPOSE

Increasing our knowledge about postoperative global Quality-Of-Recovery (QoR) after THA and TKA is important to improve perioperative medicine, in particular for preoperative patient information and benchmarking of postoperative patient status.

METHODS

This study is a single centre, retrospective cohort study of prospectively collected data, conducted in Strasbourg University Hospital, Strasbourg, France. The main outcome was the modified French version of the QoR-15 (mQoR-15F) score monitored preoperatively, at postoperative day one, three, 14 and 28. We questioned the hypothesis: would THA and TKA recovery patterns differ and would postoperative health status eventually overreach the preoperative reference?

RESULTS

The mQoR-15F was statistically higher in the THA group compared to the TKA group in POD 1 and 28 (112 ± 17 vs. 107 ± 17; p < 0.01 and 131 ± 12 vs. 127 ± 15; p = 0.02, respectively). The mean postoperative time delay to reach preoperative mQoR-15F was seven and 16 days for THA and TKA patients, respectively.

CONCLUSION

Early postoperative health status after THA and TKA differs significantly; TKA being associated with a larger early decrease of global health status compared to THA. Both THA and TKA groups global health status overreached preoperative levels after one and two weeks postoperatively. These surgery-specific recovery profiles may favor improved patient information to steer advised operative decision and set specific recovery goals as part of enhanced recovery pathways.

The impact of preoperative single low-dose dexamethasone on in-hospital prognosis in geriatric intertrochanteric fracture patients: Analysis of secondary outcomes in a randomized controlled trial

BACKGROUND

Intertrochanteric fracture in the geriatric population is associated with poor prognosis, which may be attributed to consistent stress and the systemic inflammatory response. Dexamethasone is an exogenous glucocorticoid commonly used in clinical practice for broad anti-inflammatory action. The purpose is to investigate whether a single preoperative low-dose dexamethasone can improve the in-hospital prognosis in geriatric intertrochanteric fracture patients undergoing internal fixation surgery.

METHODS

Between June 2020 and October 2022, 219 eligible patients with intertrochanteric fractures were in this study. After meeting the inclusion and exclusion criteria, 160 patients were randomly allocated to the dexamethasone or placebo groups (80 patients who are geriatric with an intertrochanteric fracture in each group). The patients in the dexamethasone group received 10 mg (2 mL) of dexamethasone intravenously, whereas the patients in the placebo group received 2 mL of saline intravenously within 30 minutes before being sent to the operating room. The efficacy-related outcomes (the first bed-chair transfer ability, in-hospital mortality, and length of stay) and safety-related outcomes (infection events and hyperglycemia) were collected for analysis.

RESULTS

There were no significant differences in the baseline characteristics between the 2 groups. The dexamethasone group had a significantly higher rate of the first bed-chair transfer than the placebo group (65.0% [52/80] vs 48.8% [39/80], relative risk = 1.46, 95% confidence interval = 1.02 to 2.11; P = .038). One patient in the dexamethasone group and 7 patients in the placebo group died during hospitalization (1.3% [1/80] vs 8.8% [7/80], relative risk = 0.92, 95% confidence interval = 0.86 to 0.99; P = .07). No differences were found in the length of stay, infections, and hyperglycemia between the 2 groups.

CONCLUSION

A single preoperative low-dose of dexamethasone can improve the in-hospital prognosis (increase the ability of the first bed-chair transfer and potentially decrease the in-hospital mortality) in geriatric intertrochanteric fracture patients after internal fixation surgery.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice?

The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.

Identification of risk factors for 1-year mortality among critically ill older adults with hip fractures surgery: A single medical center retrospective study

Aim

The purpose of this study was to analyze the potential risk factors for mortality 1 year after hip fracture surgery in critically ill older adults.

Methods

We reviewed 591 critically ill older adults who underwent hip surgery at our institution from January 2018 to April 2021. We collected baseline demographics, clinical information, and 1-year survival status of the sample patients by means of medical record systems and follow-up phone calls. Patients were divided into survival and mortality groups based on survival within 1 year after surgery.

Results

Based on the results of the 1-year postoperative follow-up of patients, we obtained 117 cases in the death group and 474 cases in the survival group, and this led to a 1-year mortality rate of 19.8% (117/591) after hip fracture in critically ill older adults at our hospital. The risk factors that influenced the 1-year postoperative mortality were identified as advanced age (HR:1.04, 95%, 1.01–1.06), preoperative arrhythmia (HR: 1.95, 95%, 1.26–2.70), high level of NLR (HR:1.03, 95%, 1.01–1.06), respiratory failure (HR: 2.63, 95%, 1.32–5.23), and acute cardiovascular failure. 5.23) and acute cardiovascular events (HR: 1.65, 95%, 1.05–2.59).

Conclusion

Advanced age, preoperative arrhythmias, high levels of NLR, postoperative respiratory failure, and acute cardiovascular events were independent risk factors for survival of critically ill older adults with hip fracture at 1 year after surgery. Therefore, laboratory tests such as high levels of preoperative NLR can be an important indicator of patient prognosis.

Perioperative Protocol of Ankle Fracture and Distal Radius Fracture Based on Enhanced Recovery after Surgery Program: A Multicenter Prospective Clinical Controlled study

Background. The enhanced recovery after surgery (ERAS) program is aimed to shorten patients’ recovery process and improve clinical outcomes. This study aimed to compare the outcomes between the ERAS program and the traditional pathway among patients with ankle fracture and distal radius fracture. Methods. This is a multicenter prospective clinical controlled study consisting of 323 consecutive adults with ankle fracture from 12 centers and 323 consecutive adults with distal radial fracture from 13 centers scheduled for open reduction and internal fixation between January 2017 and December 2018. According to the perioperative protocol, patients were divided into two groups: the ERAS group and the traditional group. The primary outcome was the patients’ satisfaction of the whole treatment on discharge and at 6 months postoperatively. The secondary outcomes include delapsed time between admission and surgery, length of hospital stay, postoperative complications, functional score, and the MOS item short form health survey-36. Results. Data describing 772 patients with ankle fracture and 658 patients with distal radius fracture were collected, of which 323 patients with ankle fracture and 323 patients with distal radial fracture were included for analysis. The patients in the ERAS group showed higher satisfaction levels on discharge and at 6 months postoperatively than in the traditional group ( $P<0.001$ ). In the subgroup analysis, patients with distal radial fracture in the ERAS group were more satisfied with the treatment ( $P=0.001$ ). Furthermore, patients with ankle fracture had less time in bed ( $P<0.001$ ) and shorter hospital stay ( $P<0.001$ ) and patients with distal radial fracture received surgery quickly after being admitted into the ward in the ERAS group than in the traditional group ( $P=0.001$ ). Conclusions. Perioperative protocol based on the ERAS program was associated with high satisfaction levels, less time in bed, and short hospital stay without increased complication rate and decreased functional outcomes.

Advantages and issues of concern regarding approaches to peripheral nerve block for total hip arthroplasty

In older patients with comorbidities, hip fractures are both an important and debilitating condition. Since multimodal and multidisciplinary perioperative strategies can hasten functional recovery after surgery improving clinical outcomes, the choice of the most effective and safest pathway represents a great challenge. A key point of concern is the anesthetic approach and above all the choice of the locoregional anesthesia combined with general or neuraxial anesthesia.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery

PURPOSE OF REVIEW

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients.

RECENT FINDINGS

FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.

Peripheral nerve blocks for hip fractures in adults

BACKGROUND

This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.

OBJECTIVES

To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018.  AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.

Standardized Care Pathways as a Means to Improve Patient Safety

The literature overwhelmingly supports standardized, evidence-based care to improve patient safety in the surgical setting, including checklists and enhanced recovery programs. Although local culture, patient complexity, and hospital setting can represent barriers to implanting standardized practices, they can be overcome with thoughtful strategies.

Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007-2014

BACKGROUND

Total hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital's safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA.

METHODS

We analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status' effect on in-hospital mortality, patient complications and LOS.

RESULTS

Patients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07).

CONCLUSIONS

Our study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.