Duration of surgery affects the risk of complications following total hip arthroplasty

The influence of operation time for hip hemiarthroplasty on complication rates and mortality in patients with femoral neck fracture: a retrospective data analysis

BACKGROUND

The aim of the present study was to investigate the influence of various factors, in particular operation time, on mortality and complication rates in patients with femoral neck fractures who have undergone hip hemiarthroplasty (HHA) and to determine a cut-off value above which mortality and complication rates increase significantly.

METHODS

Cases of patients with femoral neck fracture treated with HHA between 1 January 2017 and 31 December 2023 were screened for eligibility. Multiple logistic regressions were calculated to determine which factors (patient age, experience of surgeon, patient sex, ASA score, time to surgery, operation time) influenced the incidence of complications and mortality. The exact cut-off value for complications and mortality was determined using the Youden index of the ROC curve (sensitivity vs. specificity) of logistic regression.

RESULTS

A total of 552 patients were considered eligible for this study. During the 90-day follow-up period after HHA, 50 deaths and 34 complications were recorded, giving a mortality rate of 9.1%, and a complication rate of 6.2%. Of the 34 complications recorded, 32.3% were infections, 14.7% dislocations, 20.7% trochanteric avulsions, 11.8% periprosthetic fractures, 11.8% nerve injuries, and 8.8% deep vein thrombosis. The odds ratio (OR) of a patient experiencing a complication is 2.2% higher for every minute increase in operation time (Exponential Beta - 1 = 0.022; p = 0.0363). The OR of a patient dying is 8.8% higher for each year increase in age (Exponential Beta - 1 = 0.088; p = 0.0007). When surgery was performed by a certified orthopaedic surgeon the mortality rate lowered by 61.5% in comparison to the surgery performed by a trainee (1 - Exponential Beta = 0.594; p = 0.0120). Male patients have a 168.7% higher OR for mortality than female patients (Exponential Beta - 1 = 1.687; p = 0.0017). Patients with an operation time of ≥ 86 min. have a 111.8% higher OR for mortality than patients with an operation time of < 86 min. (Exponential Beta - 1 = 1.118).

CONCLUSION

This retrospective data analysis found that the risk of a patient experiencing a complication was 2.2% higher for every minute increase in operation time. Patients with an operation time above the cut-off of 86 min had a 111.8% higher risk of mortality than those with an operation time below the cut-off. Other influencing factors that operators should be aware of include patient age, male sex, and operator experience.

Clinical outcomes following direct anterior approach during total hip arthroplasty without hip extension: a retrospective comparative study

BACKGROUND

Traditional total hip arthroplasty (THA) using the direct anterior approach (DAA) requires a hip extension. This study aimed to compare the clinical outcomes of patients undergoing THA with DAA using either the no hip extension (NHE) or the traditional hip extension (THE) strategy.

METHODS

A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 123 patients treated between January 2020 and November 2021. The patients were categorised into two groups: NHE (84 patients) and THE (39 patients).

RESULTS

The NHE group exhibited shorter operative time and had more male participants with higher ages. Comparable outcomes were observed in the visual analogue scale, Harris Hip, and Oxford Hip scores at the final follow-up. Furthermore, complications were observed in the NHE and THE groups, including two and one greater trochanteric fractures and three and one transfusions, respectively.

CONCLUSIONS

Compared to the THE, employing the NHE strategy during THA with DAA in elderly and young female patients resulted in comparable clinical outcomes with several advantages, such as favourable surgical time. The NHE method also exhibited good safety and effectiveness. Therefore, the NHE strategy may be a favourable option for elderly and young female patients.

Standard anterior peritomy versus a small posterior incision for the implantation of the PRESERFLO microshunt

PURPOSE

To compare two approaches for the implantation of the PRESERFLO microshunt: an anterior approach (A) with a 6-8-mm peritomy and a posterior approach (P) with a 3-mm incision.

METHODS

We retrospectively analyzed 126 patients who received a PRESERFLO microshunt. We compared intraocular pressure (IOP), surgical time, medication count, and postoperative complications over nine months.

RESULTS

The baseline IOP was similar in A (21.8 ± 8.5 mm Hg) and P (23.9 ± 8.1 mm Hg) (p = 0.08). Surgical duration was significantly shorter in P (10 ± 0.4 min) than in A (26 ± 0.8 min) (p < 0.001). Postoperative IOP levels were comparable in A (10.8 ± 5.9 mm Hg) and P (10.6 ± 4.5 mm Hg) at 30 days (p = 0.62) and throughout the study (all intra-group p-values > 0.08). The preoperative medication count was 3.2 ± 1.3 drops in A and 3.3 ± 1.0 drops in P (p = 0.4). Postoperative values were 0.2 ± 0.6 in A and 0.3 ± 0.7 in P at nine months. There were no significant differences in complications and surgical revisions between groups (p-values > 0.05).

CONCLUSION

Both techniques achieved satisfactory IOP and medication count reductions and had similar safety profiles, but the posterior incision technique was 2.6 times faster than the anterior incision technique.

Improved surgical exposure and early clinical outcomes using a femoral-release-first technique in direct anterior approach during total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) performed using the direct anterior approach (DAA) has demonstrated favourable early-, mid-, and long-term outcomes. However, the traditional femoral release technique remains technically demanding and is associated with challenges and a heightened risk of complications. This study aimed to compare the clinical outcomes of patients who underwent THA with DAA performed using either the femoral-release-first (FRF) or the traditional approach (TA) strategy.

METHODS

A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 106 patients between 2018 and 2019. The patients were categorised into two groups: FRF (44 hips) and TA (69 hips).

RESULTS

The FRF group showed a reduced operative time, haemoglobin (Hb) drop, postoperative hospital stay, and more optimal acetabular cup anteversion angles. Furthermore, during the first 2 months postoperatively, the FRF group demonstrated superior visual analogue scale, Harris Hip, and Oxford Hip scores. In the TA group, two hips experienced greater trochanter fractures, and one experienced delayed incision healing.

CONCLUSIONS

Compared with the TA, employing the FRF strategy during THA with DAA resulted in improved outcomes within the first 2 months postoperatively and comparable functional recovery beyond this period. The FRF method exhibited advantages such as favourable acetabular exposure and alignment and a reduced risk of complications. Therefore, the FRF strategy may be a favourable option.

Procedure Duration, Time Under Anesthesia, and Readmissions in Direct Anterior and Posterior Approach Total Hip Arthroplasty

BACKGROUND

Operative time is related to complications in primary total hip arthroplasty (THA). This study compared operative time in direct anterior (DA) and posterior approach THA and whether differences were related to increased hospital readmissions within 90 days of discharge.

METHODS

Prospectively documented data on 3,152 consecutively performed THAs by 16 surgeons at a large Midwestern United States academic healthcare system were retrospectively reviewed. All surgeons were beyond their learning curve. Cases characterized by factors extending operative time were excluded. A total of 1,235 analysis cases were performed with the DA approach and 1,608 with the posterior approach. DA patients had lower mean body mass index (P < .001), were more likely to be classified as American Society of Anesthesiologists Physical Status 1 or 2 (P < .001), and more likely to have surgery in an ambulatory setting (P < .001).

RESULTS

Time under anesthesia was significantly longer for DA procedures by 19 to 27 minutes in hospital and ambulatory settings, respectively (P < .001). Increasing body mass index had a greater impact on anesthesia time for DA patients (P = .020). There were no differences in nontraumatic readmissions within 90 days of surgery based on surgical approach (P ≥ .480); however, significantly more DA patients classified as ASA-PS 3 or 4 were readmitted compared to those classified as ASA-PS 1 or 2 (P < .001), a difference not observed for posterior approach patients.

CONCLUSION

Anesthesia time is a modifiable risk factor for patient safety and an important factor in healthcare resource utilization. Consideration of ways to reduce DA operative times is encouraged.

Prevention of early complications following total hip replacement

Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.

The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.

PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.

Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.

Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.

The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.

Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054

Hospital-Acquired Conditions: A Review of Classical and Novel Risk Factors Following Total Hip and Knee Arthroplasties

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In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $41,000 per patient per HAC.

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In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of >35 kg/m2, male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections.

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Institution-specific (surgical) risk factors such as increased tourniquet time, an operative time of >130 minutes, bilateral procedures, a femoral nerve block, and general anesthesia increase the risk of HACs in the settings of THA and TKA.

Does the Duration of Primary and First Revision Surgery Influence the Probability of First and Subsequent Implant Failures after Extremity Sarcoma Resection and Megaprosthetic Reconstruction?

Simple Summary

Tumor endoprostheses are a common type of reconstruction after the resection of an extremity bone sarcoma. However, in the long-term, first and subsequent implant failures leading to revision surgery are common. One potential risk factor for implant failure is the length of surgery. This study investigates the impact of the length of surgery on prosthetic survival in 568 patients with sarcoma. Patients who had a first implant failure had a longer surgery; however, there were no differences in the infection-free survival, but only in the probability of mechanical failure. Patients with a subsequent revision surgery for infection had a shorter duration of surgery during the first revision. In conclusion, a shorter surgery appears beneficial; however, longer surgeries are not clearly associated with infection. In revision surgery, a longer operating time, indicating a more thorough debridement, may be desirable.

Abstract

Complications in megaprosthetic reconstruction following sarcoma resection are quite common. While several risk factors for failure have been explored, there is a scarcity of studies investigating the effect of the duration of surgery. We performed a retrospective study of 568 sarcoma patients that underwent megaprosthetic reconstruction between 1993 and 2015. Differences in the length of surgery and implant survival were assessed with the Kaplan–Meier method, the log-rank test and multivariate Cox regressions using an optimal cut-off value determined by receiver operating curves analysis using Youden’s index. 230 patients developed a first and 112 patients a subsequent prosthetic failure. The median duration of initial surgery was 210 min. Patients who developed a first failure had a longer duration of the initial surgery (225 vs. 205 min, p = 0.0001). There were no differences in the probability of infection between patients with longer and shorter duration of initial surgery (12% vs. 13% at 5 years, p = 0.492); however, the probability of mechanical failure was higher in patients with longer initial surgery (38% vs. 23% at 5 years, p = 0.006). The median length of revision surgery for the first megaprosthetic failure was 101 min. Patients who underwent first revision for infection and did not develop a second failure had a longer median duration of the first revision surgery (150 min vs. 120 min, p = 0.016). A shorter length of the initial surgery appears beneficial, however, the notion that longer operating time increases the risk of deep infection could not be reproduced in our study. In revision surgery for infection, a longer operating time, possibly indicating a more thorough debridement, appears to be associated with a lower risk for subsequent revision.

Prolonged surgical time increases the odds of complications following total knee arthroplasty

Background:

The aim of this study was to evaluate the influence of operating time on complications and readmission within 30 days of total knee arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes.

Methods:

The American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify patients 18 years of age and older who underwent TKA between 2006 and 2017, using procedural codes. Patient demographic characteristics, operation length and 30-day major and minor complication and readmission rates were captured. We used multivariable regression to determine if the rates of complications and readmission differed depending on the length of the operation, while adjusting for relevant covariables.

Results:

A total of 263 174 patients who underwent TKA were identified from the database. Their mean age was 66.8 (standard deviation 9.7) years. Within 30 days of the index procedure, 5700 patients (2.2%) experienced a major complication, 5185 (2.0%) experienced a minor complication and 7730 (3.1% of 249 746 patients from 2011 to 2017) were readmitted. Mean operation length was 91.7 minutes (range 30–240 min). After adjustment for relevant covariables, an operating time of 90 minutes or more was a significant predictor of major and minor complications as well as readmission. There was no difference in the odds of complications or readmission for operations lasting 30–49, 50–69 or 70–89 minutes (p > 0.05).

Conclusion:

Our data suggest that operating times of 90 minutes or more may be associated with an increase in the 30-day odds of complications and readmission following TKA. Further studies are needed to confirm our findings and determine the influence of surgical time on outcomes when there is increased case complexity.