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Singh T, Lavikainen LI, Halme ALE, Aaltonen R, Agarwal A, Blanker MH, Bolsunovskyi K, Cartwright R, García-Perdomo H, Gutschon R, Lee Y, Pourjamal N, Vernooij RWM, Violette PD, Haukka J, Guyatt GH, Tikkinen KAO. Timing of symptomatic venous thromboembolism after surgery: meta-analysis. Br J Surg 2023; 110:553-561. [PMID: 36912116 PMCID: PMC10364527 DOI: 10.1093/bjs/znad035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/12/2023] [Accepted: 01/22/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The timing at which venous thromboembolism (VTE) occurs after major surgery has major implications for the optimal duration of thromboprophylaxis. The aim of this study was to perform a systematic review and meta-analysis of the timing of postoperative VTE up to 4 weeks after surgery. METHODS A systematic search of MEDLINE, Scopus, and CINAHL databases was performed between 1 January 2009 and 1 April 2022. Prospective studies that recruited patients who underwent a surgical procedure and reported at least 20 symptomatic, postoperative VTE events by time were included. Two reviewers independently selected studies according to the eligibility criteria, extracted data, and evaluated risk of bias. Data were analysed with a Poisson regression model, and the GRADE approach was used to rate the certainty of evidence. RESULTS Some 6258 studies were evaluated, of which 22 (11 general, 5 urological, 4 mixed, and 2 orthopaedic postoperative surgical populations; total 1 864 875 patients and 24 927 VTE events) were eligible. Pooled evidence of moderate certainty showed that 47.1 per cent of the VTE events occurred during the first, 26.9 per cent during the second, 15.8 per cent during the third, and 10.1 per cent during the fourth week after surgery. The timing of VTE was consistent between individual studies. CONCLUSION Although nearly half of symptomatic VTE events in first 4 weeks occur during the first postoperative week, a substantial number of events occur several weeks after surgery. These data will inform clinicians and guideline developers about the duration of postoperative thromboprophylaxis.
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Affiliation(s)
- Tino Singh
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | | | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Riikka Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Kostiantyn Bolsunovskyi
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Raseborg Health Centre, City of Raseborg, Raseborg, Finland
| | - Rufus Cartwright
- Departments of Gynaecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Herney García-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Rachel Gutschon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada
| | - Yung Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Tong K, Liu H, Qin J, Pan Z, Shangguan Y, Xiao H, Wang H, Chen L, Tan Y. Current status survey of the extramural hospital management of venous thromboembolism after total hip and knee arthroplasty in China. BMC Musculoskelet Disord 2021; 22:787. [PMID: 34517870 PMCID: PMC8438984 DOI: 10.1186/s12891-021-04663-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially fatal complication after arthroplasty. Numerous prophylactic strategies and studies to reduce VTEs have focused on the duration of the hospital stay and on few extramural hospitals. This study aimed to investigate extramural hospital management of VTE after total hip/knee arthroplasty (THA/TKA) in China with a novel survey tool. METHODS A total of 180 patients undergoing arthroplasty, including 68 THA patients and 112 TKA patients, were enrolled in this study. All patients received anticoagulant treatment management. A survey querying VTE management and adherence, such as therapy information, understanding of anticoagulation, satisfaction with the ability of medical staff, and satisfaction with health care costs, was administered by a questionnaire (TKA/THA Patients' Experience with Anticoagulation in the Post-discharge Period) for quality improvement. RESULTS The average age of the patients was 65.27 ± 13.62 years. All patients knew their follow-up times. 85 % of them were suggested that re-examine at the next 14 days, and the others at the next 28 days. All patients continued to visit the orthopaedic clinic after discharge without choosing other types of outpatient services, such as an anticoagulant clinic or home visit with a nurse/pharmacist or remote evaluation by telephone. A total of 96.6 % of all patients used new oral anticoagulants, and the most common treatment duration was 2-4 weeks (93.3 %). 48 % informed their physicians that they were taking anticoagulation medications when they visited ophthalmology, dentistry, dermatology, and other departments. The overall rate of satisfaction with anticoagulation management was 81.67 %, and 6.67 % of patients were not unsatisfied with their medical expenses. Patient compliance decreased with increasing follow-up time. Continuous follow-ups after discharge significantly improved patient compliance. CONCLUSIONS These results elucidate how we can improve the quality of anticoagulation. Continuous follow-up appointments for 30 days after discharge, especially for individuals over 65 years old, significantly improved patient satisfaction and reduced the incidence of VTE and medical costs.
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Affiliation(s)
- Kai Tong
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hankun Liu
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Jun Qin
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Zhengqi Pan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Yangfan Shangguan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hao Xiao
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hua Wang
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Liaobin Chen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Yang Tan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China.
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Rezapour A, Souresrafil A, Arabloo J. Economic Evaluation of New Oral Anticoagulants in Prevention of Venous Thrombosis Following Joint Replacement Surgery: A Systematic Review. Clin Ther 2021; 43:e139-e156. [PMID: 33875243 DOI: 10.1016/j.clinthera.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The main purpose of prescribing oral anticoagulants in patients undergoing total knee and total hip replacement surgery is to prevent venous thromboembolism (VTE). The present study aimed to summarize evidence from economic evaluations regarding new oral anticoagulants (NOACs) used in VTE prophylaxis after joint replacement surgery. METHODS To obtain relevant literature on economic evaluations of NOACs used in the prevention of VTE following joint replacement surgery, we searched the Cochrane Library, PubMed, Web of Science, Embase, and Scopus, as well as specialized economic evaluation databases, for articles published from January 2008 to December 2019. Next, 2 reviewers screened the titles and abstracts of studies, extracted data from the full-text articles, and assessed the quality of the methodologies using the Quality of Health Economic Studies checklist. FINDINGS Twenty-eight studies of economic evaluations met the inclusion criteria of the research. The quality assessment showed that 20 articles had scores within the range of 75 to 100 (high quality), and 9 studies had scores within the range of 50 to 74 (moderate quality). All of the identified studies had been carried out based on modelling, and 23 studies used decision trees to model acute events after surgery. In addition, 20 studies utilized a Markov model to capture long-term complications of VTE. The results showed that rivaroxaban was more cost-effective than apixaban and dabigatran from a perspective of the health care system in the prevention of VTE after total knee and total hip replacement surgery. In addition, apixaban was associated with a lower risk for bleeding events than other NOACs, making it the most cost-effective NOAC from the perspective of the payer. IMPLICATIONS The results suggest that NOACs are cost-effective alternatives to low-molecular-weight heparins. Rivaroxaban and dabigatran were assessed as the most and least cost-effective prophylaxis options, respectively, after joint replacement surgery for the prevention of VTE. It is recommended that future research be conducted on economic evaluations of edoxaban.
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Affiliation(s)
- Aziz Rezapour
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Aghdas Souresrafil
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Jalal Arabloo
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Koutras C, Becker I, Antoniou SA, Heep H. Quality assurance in primary total hip arthroplasty. J Orthop 2020; 21:122-126. [PMID: 32255992 DOI: 10.1016/j.jor.2020.03.009] [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: 02/17/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To compare two different methods of clinical outcomes documentation and investigate the potential impact of a quality assurance program. METHODS Data on primary hip arthroplasties conducted between 2004 and 2014 were prospectively collected and analyzed. RESULTS A total of 262/3395 patients suffered a postoperative complication. A reduction of complication rate was observed between 2010 and 2014. A significant difference between the two documentation methods was found in: "cardiovascular complications", "hematoma and postoperative hemorrhage" and "reintervention". Finally, the "normalized length of hospital stay" predicted the occurrence of complications. CONCLUSION Reduction of the incidence of complications through time may be attributed to accumulated surgical experience.
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Affiliation(s)
- Christos Koutras
- Musculoskeletal Center Moenchengladbach, Neuwerk Hospital, Duenner Straße, 214-216, Moenchenglabach, Germany
| | - Isabel Becker
- University Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Stavros A Antoniou
- European University Cyprus, Medical School, Diogenous Str. 6, 2404, Engomi, Nicosia, Cyprus
| | - Hansjoerg Heep
- St. Josef Krankenhaus Essen-Werden, Propsteistraße 2, 45239, Essen, Germany
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Morton JS, Kester BS, Eftekhary N, Vigdorchik J, Long WJ, Memtsoudis SG, Poultsides LA. Thirty-Day Outcomes After Bilateral Total Hip Arthroplasty in a Nationwide Cohort. Arthroplast Today 2020; 6:405-409. [PMID: 32577485 PMCID: PMC7305265 DOI: 10.1016/j.artd.2020.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Approximately 42% of patients with end-stage osteoarthritis have bilateral disease. Although bilateral total hip arthroplasty (THA) is physiologically demanding, certain patients may benefit from simultaneous rather than staged bilateral procedures. This study examines the intraoperative differences and 30-day outcomes in patients receiving bilateral THA compared with those who underwent unilateral THA. Methods Patients undergoing THA were selected from the National Surgical Quality Improvement Program database from 2008 to 2015. Patients were selected according to those with primary and concurrent coding for Current Procedural Terminology 27130. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether concurrent THA was a risk factor for poor outcomes. Results A total of 97,804 patients and 587 patients who underwent unilateral and bilateral THA, respectively, were identified. Patients who underwent bilateral procedures were younger (57.3 vs 64.6 years, P < .001), were of lower body mass index (29.2 vs 30.2, P < .001), and had fewer comorbidities than patients who underwent unilateral procedures. Length of stay was not increased for bilateral recipients (3.13 vs 2.93 days, P = .308), although fewer were discharged to home (62.8% vs 77.6%, P < .001). The bilateral recipients required postoperative transfusions at a higher rate (29.8% vs 10.9%, P < .001) and had an increased incidence of deep wound infections on univariate analysis (1.2% vs 0.3%, P = .002). There was no increased risk of superficial infection, medical complications, or thromboembolic events for the bilateral cohort. Conclusions Although bilateral THA recipients are younger with fewer preoperative comorbidities, bilateral THA is associated with an increased rate of transfusion in a nationwide setting. With this knowledge, specific interventions should be instituted to target these procedure-specific risks.
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Affiliation(s)
- Jessica S Morton
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Disease, New York, NY, USA
| | - Benjamin S Kester
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Disease, New York, NY, USA
| | - Nima Eftekhary
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Disease, New York, NY, USA
| | - Jonathan Vigdorchik
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - William J Long
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Disease, New York, NY, USA
| | | | - Lazaros A Poultsides
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Disease, New York, NY, USA
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Dietz MJ, Ray JJ, Witten BG, Frye BM, Klein AE, Lindsey BA. Portable compression devices in total joint arthroplasty: poor outpatient compliance. Arthroplast Today 2020; 6:118-122. [PMID: 32211487 PMCID: PMC7083727 DOI: 10.1016/j.artd.2019.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/26/2019] [Accepted: 12/08/2019] [Indexed: 11/02/2022] Open
Abstract
Background Aspirin and mechanical compression devices are approved means of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty. Prior studies of mechanical compression pumps after joint arthroplasty have been limited to the inpatient setting. The purpose of this study was to evaluate outpatient compliance and utilization factors in a rural population after elective hip or knee arthroplasty. Methods Utilization for portable pneumatic compression pumps after joint arthroplasty was prospectively recorded (hours). Compliance was defined as the recommended 20 hours per day. A questionnaire 2 weeks postoperatively assessed factors that may contribute to noncompliance. Patients were followed up for 90 days postoperatively to record VTE events. Results Data were collected for 115 joint arthroplasty patients (50 hips, 65 knees). Postdischarge day one had the highest average usage at 13.2 hours/day (66.0%, range 0%-100%), but this number fell to 4.8 hours/day (24.0, range 0%-100%) by day 14. Patient compliance (>20 hours use/day) was highest on postdischarge day one at 40 patients (34.7%). By postdischarge day 14, patient compliance fell to 17 patients (14.8%). Difficulty using the pumps (P = .027) and pump-associated heat (P = .009) were significantly associated with patient compliance. A deep vein thrombosis and nonfatal pulmonary embolism were recorded in 2 separate patients. Conclusions This study demonstrated poor outpatient compliance with portable pneumatic compression devices. Poor compliance was related to pump heat and difficulty with pump use. Even with poor compliance, a low incidence of VTE events was observed.
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Affiliation(s)
- Matthew J Dietz
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Justin J Ray
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Brent G Witten
- Aurora Orthopedics, Aurora Sinai Medical Center of Aurora Health Care Metro, Milwaukee, WI, USA
| | - Benjamin M Frye
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Adam E Klein
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Brock A Lindsey
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
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Asymptomatic Deep Venous Thrombosis After Elective Hip Surgery Could Be Allowed to Remain in Place Without Thromboprophylaxis After a Minimum 2-Year Follow-Up. J Arthroplasty 2020; 35:563-568. [PMID: 31551160 DOI: 10.1016/j.arth.2019.08.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is not clear how to treat asymptomatic deep venous thromboses (DVTs) following elective hip arthroplasty because the natural course of DVTs is unclear. It is therefore valuable to understand the natural course of DVTs and their relation to thromboprophylactic methods. METHODS We followed 742 consecutive patients who underwent elective hip arthroplasty followed by mechanical or chemical prophylaxis of a DVT. All patients underwent preoperative and postoperative duplex ultrasonography of both limbs. Patients who developed postoperative DVT in the popliteal or calf vein were followed without thromboprophylaxis. DVT-positive patients were prospectively followed up with duplex ultrasonography at 3, 6, 12, and 24 months postoperatively. RESULTS Incidences of preoperative and postoperative DVTs were 3.9% and 33.0%, respectively. Nonfatal pulmonary embolism (PE) occurred in 1 patient after negative echography. All DVTs that developed in the calf vein postoperatively and without anticoagulation remained benign, and 93% of the DVTs ultimately disappeared. CONCLUSION These results confirmed that the natural course of asymptomatic distal DVTs is benign, with no risk of leading to PE. Thus, distal DVTs could be allowed to remain untreated without chemical prophylaxis to prevent PE in Asian populations.
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Patient-Centered Care: Total Hip Arthroplasty for Displaced Femoral Neck Fracture Does Not Increase Infection Risk. J Healthc Qual 2020; 42:27-36. [PMID: 31895079 DOI: 10.1097/jhq.0000000000000213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole. METHODS Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection. RESULTS Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data. CONCLUSIONS When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.
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The Use of Older Versus Newer Data in the National Surgical Quality Improvement Program Database Influences the Results of Total Hip Arthroplasty Outcomes Studies. J Am Acad Orthop Surg Glob Res Rev 2019; 3:JAAOSGlobal-D-19-00108. [PMID: 31773075 PMCID: PMC6855500 DOI: 10.5435/jaaosglobal-d-19-00108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction National databases, such as the National Surgical Quality Improvement Program (NSQIP) database, are frequently used for total hip arthroplasty (THA) studies. NSQIP variables and the population included in the database have evolved over time. These changes may influence the results of studies using different periods of data. Methods THA patients were aggregated from the 2005 to 2010 and 2011 to 2015 NSQIP data sets to define two era groups. Demographic data and 30-day perioperative outcomes were compared between the groups. As an example analysis, multivariate Poisson regression was used to determine the correlation between age and perioperative outcomes for each group. Results Of 102,411 THA patients identified, 8098 cases were from 2005 to 2010 and 94,313 were from 2011 to 2015. A number of preoperative characteristics and perioperative outcomes were significantly different between the era groups. Multivariate analysis of the 2005 to 2010 group showed that increasing age was significantly associated with urinary tract infection and length of stay (LOS), and multivariate analysis of the 2011 to 2015 group showed that age was significantly associated with urinary tract infection, LOS, 30-day mortality, unplanned reintubation, extended LOS, pneumonia, deep vein thrombosis/thrombophlebitis, blood transfusion, and return to the operating room. Conclusion Significantly more THA patients were enrolled in the NSQIP in the years between 2005 and 2015. Populations in 2005 to 2010 versus 2011 to 2015 were associated with differences in preoperative characteristics and perioperative outcomes. In an example analysis, it was shown that these differences together lead to different study results and conclusions. This needs to be considered when interpreting and conducting studies using earlier NSQIP data.
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Luthringer TA, Kester BS, Kolade O, Virk MS, Alaia MJ, Campbell KA. Shoulder Arthroplasty for Posttraumatic Arthritis Is Associated With Increased Transfusions and Longer Operative Times. J Shoulder Elb Arthroplast 2019. [DOI: 10.1177/2471549219882133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder. Methods: Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes. Results: A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger ( P = .003), more likely to be female ( P < .001), smokers ( P = .029), and diabetic ( P = .003). Diagnosis of PTA was an independent risk factor for prolonged operative times ≥160 minutes (≥1 standard deviation above the mean, P = .003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204–2.449) and increased bleeding requiring transfusion ( P < .001; OR: 2.719; 95% CI: 1.607–4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts. Conclusions: Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.
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Affiliation(s)
- Tyler A Luthringer
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Benjamin S Kester
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Oluwadamilola Kolade
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Mandeep S Virk
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
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Keller K, Hobohm L, Engelhardt M. Risk of venous thromboembolism after endoprosthetic surgeries: lower versus upper extremity endoprosthetic surgeries. Heart Vessels 2018; 34:815-823. [DOI: 10.1007/s00380-018-1305-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023]
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Pavenski K, Ward SE, Hare GMT, Freedman J, Pulendrarajah R, Pirani RA, Sheppard N, Vance C, White A, Lo N, Waddell JP, Ho A, Schemitsch EH, Kataoka M, Bogoch ER, Saini K, David Mazer C, Baker JE. A rationale for universal tranexamic acid in major joint arthroplasty: overall efficacy and impact of risk factors for transfusion. Transfusion 2018; 59:207-216. [PMID: 30383292 DOI: 10.1111/trf.14995] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury ). Outcomes were compared in pre- and post-protocol groups with χ2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.
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Affiliation(s)
- Katerina Pavenski
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, Ontario, Canada
| | - Sarah E Ward
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gregory M T Hare
- St. Michael's Hospital Centre of Excellence for Patient Blood Management, Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Freedman
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Ontario Transfusion Coordinators (ONTraC), Toronto, Ontario, Canada
| | - Robisa Pulendrarajah
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Razak A Pirani
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Sheppard
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colm Vance
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alexander White
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nick Lo
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James P Waddell
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alex Ho
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Emil H Schemitsch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark Kataoka
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Earl R Bogoch
- Division of Orthopedics, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kiran Saini
- Department of Pharmacy, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - James E Baker
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Koutras C, Becker I, Antoniou SA, Heep H. Quality assurance in revision total hip arthroplasty. J Orthop 2018; 15:909-912. [PMID: 30181685 DOI: 10.1016/j.jor.2018.08.025] [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: 06/14/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022] Open
Abstract
Objective To compare two different methods of clinical outcomes prospective documentation after revision hip arthroplasty: external and internal. Methods Chi-squared test, Fisher's exact test and binary logistic regression analyses were performed. Results Eighty one patients experienced a complication (520 arthroplasties). A significant difference was found between the two documentation methods in the variable "hematoma and postoperative hemorrhage", and a significant reduction of the internally and externally documented "total complication rate". Furthermore, the "length of hospital stay" and "duration of operation" predicted independently the occurrence of complications. Conclusion Further improvement of documentation methods is required to measure the perioperative morbidity.
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Affiliation(s)
- Christos Koutras
- Klinikum Arnsberg, Clinic for Orthopaedics, Nordring 37-41, 59821, Arnsberg, Germany
| | - Isabel Becker
- University Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Stavros A Antoniou
- 401 General Military Hospital of Athens, Kanellopoulou 6, 11527, Athens, Greece
| | - Hansjoerg Heep
- Helios Klinikum Niederberg, Clinic for Orthopaedics, Robert-Koch-Straße 2, 42549, Velbert, Germany.,University Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany
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15
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Lockwood R, Kable A, Hunter S. Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study. J Clin Nurs 2018; 27:e1048-e1060. [PMID: 29076258 DOI: 10.1111/jocn.14141] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes. BACKGROUND Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable. PARTICIPANTS There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n = 196 and control site n = 187, total population n = 383). METHODS This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia. RESULTS The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites. CONCLUSION This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients. RELEVANCE TO CLINICAL PRACTICE This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.
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Affiliation(s)
- Rosemarie Lockwood
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | - Ashley Kable
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | - Sharyn Hunter
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia
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16
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Clinical and Health System Determinants of Venous Thromboembolism Event Rates After Hip Arthroplasty: An International Comparison. Med Care 2018; 56:862-869. [PMID: 30001253 DOI: 10.1097/mlr.0000000000000959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routinely collected hospital data provide increasing opportunities to assess the performance of health care systems. Several factors may, however, influence performance measures and their interpretation between countries. OBJECTIVE We compared the occurrence of in-hospital venous thromboembolism (VTE) in patients undergoing hip replacement across 5 countries and explored factors that could explain differences across these countries. METHODS We performed cross-sectional studies independently in 5 countries: Canada; France; New Zealand; the state of California; and Switzerland. We first calculated the proportion of hospital inpatients with at least one deep vein thrombosis (DVT) or pulmonary embolism by using numerator codes from the corresponding Patient Safety Indicator. We then compared estimates from each country against a reference value (benchmark) that displayed the baseline risk of VTE in such patients. Finally, we explored length of stay, number of secondary diagnoses coded, and systematic use of ultrasound to detect DVT as potential factors that could explain between-country differences. RESULTS The rates of VTE were 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in California, and 0.37% in Switzerland, while the benchmark was 0.58% (95% confidence interval, 0.35-0.81). Factors that could partially explain differences in VTE rates between countries were hospital length of stay, number of secondary diagnoses coded, and proportion of patients who received lower limb ultrasound to screen for DVT systematically before hospital discharge. An exploration of the French data showed that the systematic use of ultrasound may be associated with over detection of DVT but not pulmonary embolism. CONCLUSIONS In-hospital VTE rates after arthroplasty vary widely across countries, and a combination of clinical, data-related, and health system factors explain some of the variations in VTE rates across countries.
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17
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McLynn RP, Diaz-Collado PJ, Ottesen TD, Ondeck NT, Cui JJ, Bovonratwet P, Shultz BN, Grauer JN. Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery. Spine J 2018; 18:970-978. [PMID: 29056565 DOI: 10.1016/j.spinee.2017.10.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/01/2017] [Accepted: 10/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Venous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery. PURPOSE The objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery. STUDY DESIGN/SETTING This is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center. PATIENT SAMPLE This study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery. OUTCOME MEASURES The incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort. MATERIALS AND METHODS Associations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression. RESULTS Among 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048). CONCLUSIONS Pharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.
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Affiliation(s)
- Ryan P McLynn
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Pablo J Diaz-Collado
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Jonathan J Cui
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Blake N Shultz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA.
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18
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Zusmanovich M, Kester BS, Schwarzkopf R. Postoperative Complications of Total Joint Arthroplasty in Obese Patients Stratified by BMI. J Arthroplasty 2018; 33:856-864. [PMID: 29089223 DOI: 10.1016/j.arth.2017.09.067] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/13/2017] [Accepted: 09/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND High body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. Many studies have evaluated this trend, but few have looked at the rates of complications based on BMI as a continuous variable. The purpose of this study was to stratify obese patients into 3 BMI categories and evaluate their rates of complications and gauge whether transitioning from higher to lower BMI category lowers complication. METHODS Patients undergoing primary total joint arthroplasty were selected from the National Surgical Quality Improvement Program database from 2008-2015 and arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m2), O2 (BMI 35-39.9 kg/m2), and O3 (BMI >40 kg/m2). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI. RESULTS A total of 268,663 patients were identified. Patients with a BMI >30 kg/m2 had more infectious and medical complications compared with nonobese patients. Furthermore, there were increased complications as the BMI categories increased. Patients with a BMI >40 kg/m2 (O3) had longer operating times, length of stay, higher rates of readmissions, reoperations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. These trends were present when comparing the O2 with O1 category as well. CONCLUSION We have demonstrated increased rates of medical and surgical complications in obese patients. Furthermore, we demonstrated a stepwise increase in complication rates when transitioning to higher BMI groups. Based on our data, we believe that preoperative counseling and interventions to decrease BMI should be explored before offering elective surgery to obese patients.
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Affiliation(s)
- Mikhail Zusmanovich
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Benjamin S Kester
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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19
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Zusmanovich M, Kester B, Feng J, Schwarzkopf R. Postoperative complications in underweight patients undergoing total hip arthroplasty: A comparative analysis to normal weight patients. J Orthop 2018; 15:345-348. [PMID: 29881150 DOI: 10.1016/j.jor.2018.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/18/2018] [Indexed: 01/28/2023] Open
Abstract
Background Underweight patients undergoing total hip arthroplasty have been largely overlooked. The purpose of this study was to evaluate their complications profiles compared to normal weight individuals. Methods Patients were selected from the NSQIP database, matched, and arranged into 2 groups based on BMI. Complications were recorded and analyzed to determine differences in outcomes. Results Multivariate analysis demonstrated increased length of hospital stay (LOS) (p = 0.006) for underweight patients but failed to demonstrate higher rates of medical or surgical complications. Conclusion There are no increased rates of infectious or medical complications in underweight patients undergoing THA. However, increased LOS was demonstrated.
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Affiliation(s)
- Mikhail Zusmanovich
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, 10003, United States
| | - Benjamin Kester
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, 10003, United States
| | - James Feng
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, 10003, United States
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, 10003, United States
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20
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Alizadeh RF, Sujatha-Bhaskar S, Li S, Stamos MJ, Nguyen NT. Venous thromboembolism in common laparoscopic abdominal surgical operations. Am J Surg 2017; 214:1127-1132. [DOI: 10.1016/j.amjsurg.2017.08.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/30/2017] [Accepted: 08/05/2017] [Indexed: 11/27/2022]
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21
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Courtney PM, Boniello AJ, Levine BR, Sheth NP, Paprosky WG. Are Revision Hip Arthroplasty Patients at Higher Risk for Venous Thromboembolic Events Than Primary Hip Arthroplasty Patients? J Arthroplasty 2017; 32:3752-3756. [PMID: 28807468 DOI: 10.1016/j.arth.2017.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/29/2017] [Accepted: 07/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to determine whether revision total hip arthroplasty (THA) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) when compared to primary THA. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database for all primary and revision THA cases from 2011 to 2014. Demographic data, medical comorbidities, and venous thromboembolic rates within 30 days of surgery were compared between the primary and revision THA groups. RESULTS Revision THA had a higher rate of DVT than the primary THA (0.6% vs 0.4%, P = .016), but there was no difference in the rate of PE (0.3% vs 0.2%, P = .116). When controlling for confounding variables, revision surgery alone was not a risk factor for DVT (odds ratio 0.833, 95% confidence interval 0.564-1.232) or PE (odds ratio 1.009, 95% confidence interval 0.630-1.616). Independent risk factors for DVT include age >70 years, malnutrition, infection, operating time >3 hours, general anesthesia, American Society of Anesthesiologists classification 4 or greater, and kidney disease (all P < .05). Probability of DVT ranged from 0.2% with zero risk factors to 10% with all risk factors. Independent risk factors for PE included age >70 years, African American ethnicity, and operating time >3 hours (all P < .05) with probabilities of PE postoperatively ranging from 0.2% to 1.1% with all risk factors. CONCLUSION Revision surgery alone is not a risk factor for venous thromboembolism after hip arthroplasty. Surgeons should weigh the risks and benefits of more aggressive anticoagulation in certain high-risk patients.
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Affiliation(s)
- P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anthony J Boniello
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Wayne G Paprosky
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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22
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Tanenbaum JE, Knapik DM, Fitzgerald SJ, Marcus RE. National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population. J Arthroplasty 2017; 32:2941-2946. [PMID: 28602536 DOI: 10.1016/j.arth.2017.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population. METHODS All patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA. RESULTS We identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA. CONCLUSION The national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.
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Affiliation(s)
- Joseph E Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Derrick M Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Steven J Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
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23
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Tanenbaum JE, Knapik DM, Wera GD, Fitzgerald SJ. National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population. J Arthroplasty 2017; 32:2669-2675. [PMID: 28511946 PMCID: PMC5572751 DOI: 10.1016/j.arth.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/24/2017] [Accepted: 04/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA. METHODS All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics. RESULTS In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76). CONCLUSION The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population.
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Affiliation(s)
- Joseph E. Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA,Corresponding Author: Joseph Tanenbaum, Department of Orthopedic Surgery, University Hospital Case Medical Center, 11100 Euclid Avenue, Cleveland, Ohio 44106, Tel: 518-369-1053,
| | - Derrick M. Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
| | - Glenn D. Wera
- Department of Orthopedic Surgery, Metro Health Medical Center, Cleveland, Ohio, USA
| | - Steven J. Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
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24
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Saleh J, El-Othmani MM, Saleh KJ. Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery. Orthop Clin North Am 2017; 48:127-135. [PMID: 28336037 DOI: 10.1016/j.ocl.2016.12.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.
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Affiliation(s)
- Jasmine Saleh
- Department of Research Institute, National Institute of Health, 9000 Rockville Pike Street, Bethesda, MD 20892, USA
| | - Mouhanad M El-Othmani
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA
| | - Khaled J Saleh
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA.
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Periarticular Injection of Liposomal Bupivacaine Offers No Benefit Over Standard Bupivacaine in Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. J Arthroplasty 2017; 32:628-634. [PMID: 27667533 DOI: 10.1016/j.arth.2016.07.023] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periarticular injection of liposomal bupivacaine has been adopted as part of multimodal pain management after total knee arthroplasty (TKA). METHODS In this prospective, randomized clinical trial, we enrolled 162 patients undergoing primary TKA in a single institution between January 2014 and May 2015. Eighty-seven patients were randomized to liposomal bupivacaine (experimental group), and 75 patients were randomized to free bupivacaine (control group). All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Outcomes evaluated include the patient-reported visual analog pain scores, narcotic consumption, and narcotic-related side effects (Brief Pain Inventory) within 96 hours after surgery as well as functional outcomes using the Knee Society Score and the Short-Form 12 measured preoperatively and at 4-6 weeks after surgery. RESULTS There were no statistically significant differences between the groups in terms of postoperative daily pain scores, narcotic consumption (by-day and overall), or narcotic-related side effects. There were no statistically significant differences between the groups in terms of surgical (P = .76) and medical complications or length of hospital stay (P = .35). There were no statistically significant differences in satisfaction between the groups (P = .56) or between the groups in postoperative Knee Society Score (P = .53) and the Short-Form 12 at 4-6 weeks (P = .82, P = .66). CONCLUSION As part of multimodal pain management protocol, periarticular injection of liposomal bupivacaine compared with bupivacaine HCl did not result in any clinically or statistically significant improvement of the measured outcomes following TKA.
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Lovecchio F, Alvi H, Sahota S, Beal M, Manning D. Is Outpatient Arthroplasty as Safe as Fast-Track Inpatient Arthroplasty? A Propensity Score Matched Analysis. J Arthroplasty 2016; 31:197-201. [PMID: 27378634 DOI: 10.1016/j.arth.2016.05.037] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/29/2016] [Accepted: 05/12/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient total joint arthroplasty is attractive provided the incidence of costly complications is comparable to contemporary "fast-track" inpatient pathways. METHODS All patients undergoing total hip arthroplasty or total knee arthroplasty between 2011 and 2013 were selected from the American College of Surgeons-National Surgical Quality Improvement Program database. A propensity score was used to match 1476 fast-track (≤2 day length of stay) inpatients with 492 outpatients (3:1 ratio). Thirty-day complication, reoperation, and readmission rates were compared, both during and after hospitalization. Logistic regression was used to calculate propensity score adjusted odds ratios. RESULTS After matching, outpatients had higher rates of medical complication (anytime, 10.0% vs 6.7%, P = .018; post discharge, 6.3% vs 1.1%, P < .001). Most complications were bleeding requiring transfusion, which occurred at similar rates after surgery but at higher rates post discharge in outpatients (anytime, 7.5% outpatients vs 5.6% inpatients, P = .113; post discharge, 4.1% outpatients vs 0.1% inpatients, P < .001). There was no difference in readmission rate (2.4% outpatient vs 2.0% inpatient, P = .589). CONCLUSION Outpatients experience higher rates of post-discharge complications, which may countermand cost savings. Surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post-discharge medical complications to include blood management strategies.
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Affiliation(s)
- Francis Lovecchio
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hasham Alvi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shawn Sahota
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew Beal
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Manning
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kester BS, Minhas SV, Vigdorchik JM, Schwarzkopf R. Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification? J Arthroplasty 2016; 31:1649-1653.e1. [PMID: 26961087 DOI: 10.1016/j.arth.2016.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts. METHODS Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes. RESULTS A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission. CONCLUSION We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.
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Affiliation(s)
- Benjamin S Kester
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Shobhit V Minhas
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Jonathan M Vigdorchik
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
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Minhas SV, Goyal P, Patel AA. What are the Risk Factors for Cerebrovascular Accidents After Elective Orthopaedic Surgery? Clin Orthop Relat Res 2016; 474:611-8. [PMID: 26290342 PMCID: PMC4746182 DOI: 10.1007/s11999-015-4496-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/31/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative cerebrovascular accidents (CVAs) are one of the leading causes of patient morbidity, mortality, and medical costs. However, little is known regarding the rates of these events and risk factors for CVA after elective orthopaedic surgery. QUESTIONS/PURPOSES Our goals were to (1) establish the national, baseline proportion of patients experiencing a 30-day CVA and the timing of CVA; and (2) determine independent risk factors for 30-day CVA rates after common elective orthopaedic procedures. METHODS Patients undergoing elective TKA, THA, posterior or posterolateral lumbar fusion, anterior cervical discectomy and fusion, and total shoulder arthroplasty, from 2006 to 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program(®) database. A total of 42,150 patients met inclusion criteria. Thirty-day CVA rates were recorded for each procedure, and patients were assessed for characteristics associated with CVA through univariate analysis. Multivariate regression models were created to identify independent risk factors for CVA. RESULTS A total of 55 (0.13%) patients experienced a CVA within 30 days of the procedure, occurring a median of 2 days after surgery (range, 1-30 days) with 0.08% of patients experiencing a CVA after TKA, 0.15% after THA, 0.00% after single-level anterior cervical discectomy and fusion, 0.38% after multilevel anterior cervical discectomy and fusions, 0.20% after single-level posterior or posterolateral lumbar fusion, 0.70% after multilevel posterior or posterolateral lumbar fusion, and 0.22% after total shoulder arthroplasty. Independent risk factors for CVA included age of 75 years or older (odds ratio [OR], 2.50; 95% CI, 1.44-4.35; p = 0.001), insulin-dependent diabetes mellitus (OR, 3.08; CI, 1.47-6.45; p = 0.003), hypertension (OR, 2.71; CI, 1.19-6.13; p = 0.017), history of transient ischemic attack (OR, 2.83; CI, 1.24-6.45; p = 0.013), dyspnea (OR, 2.51; CI, 1.30-4.86; p = 0.006), chronic obstructive pulmonary disease (OR, 2.33; CI, 1.06-5.13; p = 0.036), and operative time of 180 minutes or greater (OR, 3.25; CI 1.60-6.60; p = 0.001). CONCLUSIONS Numerous nonmodifiable patient comorbidities and increased operative time were associated with CVA after elective orthopaedic procedures. However, the American College of Surgeons National Surgical Quality Improvement Program(®) database does not code for cardiac arrhythmia or atrial fibrillation, which other studies have suggested may be important predictor variables; those may be important risk factors, although we were unable to evaluate them in our study. Surgeons should counsel patients with these risk factors and limit their operative time to reduce the risk of these adverse events, and future studies should examine other patient characteristics such as arrhythmia and noncoronary heart disease and assess the role of pharmacologic prophylaxis in patients with these risk factors. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Shobhit V Minhas
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Preeya Goyal
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, NMH/Arkes Family Pavilion, Suite 1350, Chicago, IL, 60611, USA.
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Algattas H, Kimmell KT, Vates GE. Risk of Reoperation for Hemorrhage in Patients After Craniotomy. World Neurosurg 2016; 87:531-9. [DOI: 10.1016/j.wneu.2015.09.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/11/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
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Tang L, Wu YY, Lip GYH, Yin P, Hu Y. Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 3:e30-44. [PMID: 26765646 DOI: 10.1016/s2352-3026(15)00228-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings. METHODS In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504. FINDINGS Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46). INTERPRETATION Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients. FUNDING National Natural Science Foundation.
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Affiliation(s)
- Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Ying Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Analysis of Venous Thromboembolism Risk in Patients Undergoing Craniotomy. World Neurosurg 2015; 84:1372-9. [DOI: 10.1016/j.wneu.2015.06.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 11/20/2022]
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