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Magaldi RJ, Strecker SE, Nissen CW, Witmer DK, Carangelo RJ. Preoperative Bladder Scanning Can Predict Postoperative Urinary Retention Following Total Joint Arthroplasty. J Bone Joint Surg Am 2024; 106:569-574. [PMID: 38377182 DOI: 10.2106/jbjs.23.00841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND As total joint arthroplasty (TJA) moves to the outpatient setting, it is becoming clear that postoperative urinary retention (POUR) is a potential impediment to same-day discharge. Although risk factors for POUR have been widely studied, the lack of their clinical utility warrants investigation of specific preoperative factors that can assist in surgical planning and patient optimization. The purpose of the current study was to determine whether preoperative symptom surveys and bladder scanning are useful tools in identifying POUR risk. METHODS We performed a prospective analysis of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a high-volume orthopaedic hospital between December 1, 2020, and September 30, 2021. A total of 507 patients (324 female and 183 male) undergoing TJA completed the American Urological Association (AUA) symptom index preoperatively and then again at 14 and 64 days postoperatively. Post-void bladder scans were obtained in the immediate preoperative setting. POUR was defined as a bladder volume of >500 mL that required catheterization. Chi-square and quintile analysis were used to compare bladder scanning volumes, and Student t tests were used to compare AUA scores. RESULTS The rate of POUR was 37% (66 female and 34 male) and 23% (37 female and 19 male) in the TKA and THA groups, respectively. Increasing post-void residual volume (PVRV) measured on preoperative bladder scanning was found to be predictive of POUR. Among the TKA cohort, younger age and lower body mass index were also associated with increased catheterization, although age was not statistically significant. The AUA symptom survey was not found to correlate with POUR in either population. CONCLUSIONS There was a predictable and exponential increase in the rate of catheterization as preoperative PVRV increased from 50 to 200 mL. The AUA symptom score showed no utility in predicting POUR in our study population. We propose that preoperative bladder ultrasonography become standard practice in TJA, especially among patients scheduled for same-day discharge. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Robert James Magaldi
- Division of Orthopaedic Surgery, Jefferson Health, Stratford, New Jersey
- Bone and Joint Institute, Hartford Hospital, Hartford, Connecticut
| | | | - Carl W Nissen
- Bone and Joint Institute, Hartford Hospital, Hartford, Connecticut
| | - Dan K Witmer
- Bone and Joint Institute, Hartford Hospital, Hartford, Connecticut
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2
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Di Martino A, Brunello M, Pederiva D, Schilardi F, Rossomando V, Cataldi P, D'Agostino C, Genco R, Faldini C. Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review. Clin Pract 2023; 13:569-582. [PMID: 37218803 DOI: 10.3390/clinpract13030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023] Open
Abstract
The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Matteo Brunello
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Davide Pederiva
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Francesco Schilardi
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Valentino Rossomando
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Piergiorgio Cataldi
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Claudio D'Agostino
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Rossana Genco
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Cesare Faldini
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
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Greimel F, Maderbacher G. [Perioperative management in fast-track arthroplasty]. DER ORTHOPADE 2022; 51:366-373. [PMID: 35412089 DOI: 10.1007/s00132-022-04244-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Abstract
The optimization of organizational processes, as well as surgical procedures intra- and perioperatively, are essential components with respect to fast-track programs in clinical routine. Treatment concepts focus on early postoperative mobilization of patients after joint replacement surgery in an interdisciplinary setting to avoid pain and complications on a scientific basis. This article gives a comprehensive and detailed overview regarding evidence-based peri- and intraoperative fast-track treatment methods: from pain treatment with intraoperative local infiltration analgesia and tranexamic acid application under minimally invasive surgical approach in short-lasting spinal anesthesia to renunciation of drains, regional pain- and urinary catheters, tourniquets, and restrictions.
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Affiliation(s)
- Felix Greimel
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Günther Maderbacher
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
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Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis. J Knee Surg 2022; 36:779-784. [PMID: 35259763 DOI: 10.1055/s-0042-1743227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Same-day discharge pathways in total knee arthroplasty (TKA) are gaining popularity as a means to increase patient satisfaction and reduce overall costs, but these pathways have not been thoroughly evaluated in potentially at-risk populations, such as in patients ≥80 years old. The purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary TKA in patients ≥80 years old and those <80 years old. Patients who underwent unilateral primary TKA, were discharged on postoperative day 0, and had a minimum 90-day follow-up were identified in a national insurance claims database (PearlDiver Technologies) using Current Procedural Terminology code 27447. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). These cohorts were propensity matched based upon sex, Charlson comorbidity index, and obesity status. Univariate analysis was performed to determine differences in 90-day complications and mortality between the two cohorts. In total, 1,111 patients were included in each cohort. Both cohorts were successfully matched, with no observed differences in matched parameters for demographics or comorbidities. There was no significant difference in 90-day mortality between the two cohorts (p = 0.896). However, octogenarians were at significantly increased risk of postoperative atrial fibrillation (20.8 vs. 10.4%; p < 0.001), nonatrial fibrillation arrhythmias (8.4 vs. 5.6%; p = 0.009), pneumonia (4.5 vs. 2.2%; p = 0.002), stroke (3.1 vs. 1.7%; p = 0.037), heart failure (10.5 vs. 7.5%; p = 0.012), and urinary tract infection (UTI; 14.3 vs. 9.4%; p < 0.001) compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary TKA, including cardiopulmonary complications, stroke, and UTI. Clinicians should be cognizant of these complications and counsel patients appropriately when electing to perform same-day TKA in the octogenarian population.
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Azam MQ, Goyal T, Paul S, Yadav AK, Govil N. Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:711-717. [PMID: 34097154 DOI: 10.1007/s00590-021-03031-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes. METHODS Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted. RESULTS We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups. CONCLUSION ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways. LEVEL OF EVIDENCE Level II, Prospective comparative study.
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Affiliation(s)
- Md Quamar Azam
- Department of Trauma Surgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India.
| | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Arvind Kumar Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Nishith Govil
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
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Møller T, Engedal MS, Plum LM, Aasvang EK. Reduced Need for Urinary Bladder Catheterization in the Postanesthesia Care Unit After Implementation of an Evidence-based Protocol: A Prospective Cohort Comparison Study. EUR UROL SUPPL 2021; 26:27-34. [PMID: 34337505 PMCID: PMC8317857 DOI: 10.1016/j.euros.2021.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/05/2022] Open
Abstract
Background Postoperative urinary retention (POUR) is a known complication in the postanesthesia care unit (PACU). The variations in catheterization thresholds contribute to unnecessary invasive procedures. Objective In the current study, we implemented an algorithm for a sterile intermittent catheterization (SIC) threshold of 800 ml with volume-dependent bladder scan intervals and compared the incidence of SIC with that of a matched patient cohort threshold of 400 ml. Design, setting, and participants This comparative study of two prospective historical cohorts represented two thresholds for POUR, set at 400 ml without a standardized bladder scan protocol and 800 ml with a volume-dependent bladder scan protocol. Outcome measurements and statistical analysis The primary outcome was the frequency of catheterization during the PACU stay. Secondary outcomes evaluated patient safety aspects in occurrence of thresholds above 400/800 ml. The study was set at the PACU under the Department of Anesthesia, Center for Cancer and Organ Diseases, Rigshospitalet, Denmark. Results and limitations In total, 741 patients were consecutively included, with 307 in the POUR-400 and 434 in the POUR-800 group, and with comparable group characteristics. Significantly fewer patients fulfilled the SIC/catheter a’ demeure (CAD) criteria in the POUR-800 (5.0%) versus POUR-400 (14.3%) group, equivalent to a 65.0% relative reduction in SIC. Conclusions Implementation of a standardized ultrasound-guided protocol with volume-dependent scan intervals and an evidence-based catheterization threshold of 800 ml decreases the need for SIC by >65%, without increasing the need for urinary catheterization at the wards. Patient summary In this study, we implemented an algorithm for a sterile intermittent catheterization threshold of 800 ml with volume-dependent bladder scan intervals. A marked reduction was seen in catheterization in the postanesthesia care unit, without increasing catheterization rates at the ward.
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Affiliation(s)
- Tom Møller
- Anesthesiological Department of the Center for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Institute of Public health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mette S Engedal
- Anesthesiological Department of the Center for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lise M Plum
- Abdominal Surgical Department of the Center for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Eske K Aasvang
- Anesthesiological Department of the Center for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Clarius M, Clarius LM. [Fast-track arthroplasty-intra- and post-operative management]. DER ORTHOPADE 2020; 49:318-323. [PMID: 31974634 DOI: 10.1007/s00132-020-03867-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fast-track concepts in hip and knee arthroplasty focus on an early and safe mobilisation after surgery using a multi-modal pain concept with local infiltration anaesthesia. No drains, femoral nerve blocks or urinary catheters are used. Tranexamic acid reduces blood loss and transfusion rates. Cortisone is helpful in reducing pain, PONV and postsurgical stress response. Minimal invasive surgical techniques and the renouncement of a tourniquet lead to a better functional result and less pain. Restrictions and precautions are not evidence-based and should, therefore, be abandoned.
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Affiliation(s)
- M Clarius
- Vulpius Klinik GmbH, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.
| | - L M Clarius
- Vulpius Klinik GmbH, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
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8
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Ziemba-Davis M, Nielson M, Kraus K, Duncan N, Nayyar N, Meneghini RM. Identifiable Risk Factors to Minimize Postoperative Urinary Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty. J Arthroplasty 2019; 34:S343-S347. [PMID: 30956046 DOI: 10.1016/j.arth.2019.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative urinary retention (POUR) following total joint arthroplasty (TJA) presents a significant barrier to outpatient and early discharge TJA. This study examined the incidence and risk factors for acute POUR in a modern, evidence-based, outpatient, and early discharge TJA program. METHODS Prospectively recorded data on 685 consecutive primary unilateral TJAs discharged the day of or day after surgery were retrospectively reviewed. POUR was diagnosed by a perioperative internal medicine specialist. Univariate analysis of potential predictors was performed, followed by binary logistic regression (BLR) testing of predictors with P ≤ .25. RESULTS After exclusions for confounds, the final analysis sample consisted of 633 procedures. The overall incidence of POUR was 5.5% (3.9% for same day discharges). Male gender, history of urinary retention, use of rocuronium, use of glycopryrrolate, use of neostigmine, fentanyl spinals, and the absence of an indwelling urethral catheter were associated with acute POUR and met criteria for entry into multivariate BLR. Seventeen additional predictors, including kidney disease and outpatient surgery were unrelated to POUR. In the final BLR model (P = .001), male patients who received glycopyrrolate with neostigmine had a 34% probability of developing POUR, which declined to 2.8% in the absence of these risk factors. CONCLUSION Despite a relatively low incidence of 5.5%, avoidance of anticholinergics and cholinesterase inhibitors during anesthesia should be carefully considered in outpatient TJA, particularly in stand-alone ambulatory surgery centers.
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Affiliation(s)
- Mary Ziemba-Davis
- Department of Orthopedics, Indiana University Health Orthopedics, Fishers, IN
| | - Mark Nielson
- Anesthesia Consultants of Indiana LLC, Indianapolis, IN
| | - Kent Kraus
- Indiana University School of Medicine, Indianapolis, IN
| | - Nathan Duncan
- Indiana University School of Medicine, Indianapolis, IN
| | - Nimra Nayyar
- Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopedics, Indiana University Health Orthopedics, Fishers, IN; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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9
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Ma Y, Lu X. Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial. BMC Musculoskelet Disord 2019; 20:11. [PMID: 30611266 PMCID: PMC6320613 DOI: 10.1186/s12891-018-2395-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/26/2018] [Indexed: 01/16/2023] Open
Abstract
Background The purpose of this study was to investigate whether patients undergoing total joint arthroplasty (TJA) require catheterization. Methods PubMed, EMBASE, Web of Science, Cochrane Library and China National Knowledge Infrastructure were systematically searched. All randomized controlled trials (RCTs) receiving either a urinary catheterization or no urinary catheterization were included. Meta-analysis results were assessed by RevMan 5.3 software. Results Seven independent RCTs were included, with a total sample size of 1533 patients, including 750 patients in the indwelling catheter group and 783 patients in the none-indwelling catheter group. Our pooled data analysis indicated that patients in the indwelling catheter group had a higher risk of urinary tract infection than patients in the none-indwelling catheter group (RR, 3.21; P = 0.0003). However, the meta-analysis indicated that there was no significant difference between the two groups in terms of urinary retention (RR, 0.67; P = 0.13), duration of the surgery (MD, − 0.37; P = 0.55), and length of hospital stay (MD, 0.15; P = 0.38). Conclusion Based on the current evidence, this meta-analysis showed that urinary catheterization during TJA can increase the postoperative urinary tract infection, and it may not routinely be required for the patients undergoing TJA. Level of evidence Level I, therapeutic study.
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Affiliation(s)
- Yimei Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, People's Republic of China
| | - Xiaoxi Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, People's Republic of China.
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10
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Halawi MJ, Caminiti N, Cote MP, Lindsay AD, Williams VJ. The Most Significant Risk Factors for Urinary Retention in Fast-track Total Joint Arthroplasty are Iatrogenic. J Arthroplasty 2019; 34:136-139. [PMID: 30268444 DOI: 10.1016/j.arth.2018.08.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/08/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay. METHODS Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors. RESULTS One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001). CONCLUSION The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged.
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Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Nicholas Caminiti
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Adam D Lindsay
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Vincent J Williams
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
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11
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Xie T, Ma B, Li Y, Zou J, Qiu X, Chen H, Wang C, Rui Y. [Research status of the enhanced recovery after surgery in the geriatric hip fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1038-1046. [PMID: 30238732 DOI: 10.7507/1002-1892.201712083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the latest developments in the enhanced recovery after surgery (ERAS) in the geriatric hip fractures and its perioperative therapy management. Methods The recent original literature on the ERAS in the geriatric hip fractures were extensively reviewed, illustrating the concepts and properties of the ERAS in the geriatric hip fractures. Results It has been considered to be associated with the decreased postoperative morbidity, reduced hospital length of stay, and cost savings to implement ERAS protocols, including multimodal analgesia, inflammation control, intravenous fluid therapy, early mobilization, psychological counseling, and so on, in the perioperative (emergency, preoperative, intraoperative, postoperative) management of the geriatric hip fractures. The application of ERAS in the geriatric hip fractures guarantees the health benefits of patients and saves medical expenses, which also provides basis and guidance for the further development and improvement of the entire process perioperative management in the geriatric hip fractures. Conclusion Significant progress has been made in the application of ERAS in the geriatric hip fractures. ERAS protocols should be a priority for perioperative therapy management in the geriatric hip fractures.
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Affiliation(s)
- Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Binbin Ma
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yingjuan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Jihong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiaodong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009,
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12
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Low incidence of postoperative urinary retention with the use of a nurse-led bladder scan protocol after hip and knee arthroplasty: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:283-289. [DOI: 10.1007/s00590-017-2042-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/09/2017] [Indexed: 12/28/2022]
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Bjerregaard LS, Hornum U, Troldborg C, Bogoe S, Bagi P, Kehlet H. Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty: A Randomized, Open-label, Controlled Trial. Anesthesiology 2017; 124:1256-64. [PMID: 27054365 DOI: 10.1097/aln.0000000000001112] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND No evidence-based threshold exists for postoperative urinary bladder catheterization. The authors hypothesized that a catheterization threshold of 800 ml was superior to 500 ml in reducing postoperative urinary catheterization and urological complications after fast-track total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS This was a randomized, controlled, open-label trial that included patients greater than or equal to 18 yr who underwent THA or TKA in three Danish, fast-track, orthopedic departments. Consenting patients were eligible if they were cooperative and understood Danish. Participants were randomly allocated to a catheterization threshold of 500 or 800 ml, using opaque sealed envelopes. Group assignment was unmasked. Ultrasound bladder scans were performed every second hour until the first voluntary micturition, with subsequent urinary catheterization according to group assignment. The primary outcome was the number of patients catheterized before their first voluntary micturition. Thirty-day telephonic follow-up was on voiding difficulties, urinary tract infections, and readmissions. RESULTS Of 800 patients allocated, 721 (90%) were included in a per-protocol analysis (20 did not complete the study and 59 were excluded from the analysis). In the 500-ml group, 32.2% received catheterization (114 of 354) compared to 13.4% (49 of 367) in the 800-ml group (relative risk, 0.4; 95% CI, 0.3 to 0.6; P < 0.0001). The authors found no difference between groups in any secondary outcome. CONCLUSIONS In fast-track THA and TKA, a catheterization threshold of 800 ml significantly reduced the need for postoperative urinary catheterization, without increasing urological complications. This large randomized, controlled trial may serve as a basis for evidence-based guidelines on perioperative urinary bladder management.
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Affiliation(s)
- Lars S Bjerregaard
- From the Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen University, Copenhagen, Denmark (L.S.B., H.K.); Orthopaedic Department, Aalborg University Hospital, Farsoe Clinic, Farsoe, Denmark (U.H.); Orthopaedic Department, Vejle Hospital, Vejle, Denmark (C.T.); Orthopaedic Department, Gentofte Hospital, Copenhagen University, Gentofte, Denmark (S.B.); Department of Urology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark (P.B.); and The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark (L.S.B., U.H., C.T., S.B., P.B., H.K.)
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14
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Maempel JF, Clement ND, Ballantyne JA, Dunstan E. Enhanced recovery programmes after total hip arthroplasty can result in reduced length of hospital stay without compromising functional outcome. Bone Joint J 2016; 98-B:475-82. [DOI: 10.1302/0301-620x.98b4.36243] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/04/2015] [Indexed: 12/27/2022]
Abstract
Aims The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. Patients and Methods Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. Results The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). Conclusion We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. Take home message: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality. Cite this article: Bone Joint J 2016;98-B:475–82.
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Affiliation(s)
- J. F. Maempel
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | - N. D. Clement
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | | | - E. Dunstan
- Victoria Hospital , Hayfield
Road, Kirkcaldy KY2 5AH, Fife, UK
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15
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Kehlet H, Aasvang EK. Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence? F1000Res 2015; 4. [PMID: 26918127 PMCID: PMC4753997 DOI: 10.12688/f1000research.7100.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 12/21/2022] Open
Abstract
Regional anesthesia for knee and hip arthroplasty may have favorable outcome effects compared with general anesthesia by effectively blocking afferent input, providing initial postoperative analgesia, reducing endocrine metabolic responses, and providing sympathetic blockade with reduced bleeding and less risk of thromboembolic complications but with undesirable effects on lower limb motor and urinary bladder function. Old randomized studies supported the use of regional anesthesia with fewer postoperative pulmonary and thromboembolic complications, and this has been supported by recent large non-randomized epidemiological database cohort studies. In contrast, the data from newer randomized trials are conflicting, and recent studies using modern general anesthetic techniques may potentially support the use of general versus spinal anesthesia. In summary, the lack of properly designed large randomized controlled trials comparing modern general anesthesia and spinal anesthesia for knee and hip arthroplasty prevents final recommendations and calls for prospective detailed studies in this clinically important field.
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Affiliation(s)
- Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; The Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement, Copenhagen, Denmark
| | - Eske Kvanner Aasvang
- Anesthesiological Department of the Abdominal Centre and Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Blegdamsvej 9, DK-2100, Denmark
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Aasvang E, Luna I, Kehlet H. Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Br J Anaesth 2015. [DOI: 10.1093/bja/aev257] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0130636. [PMID: 26146830 PMCID: PMC4492963 DOI: 10.1371/journal.pone.0130636] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/21/2015] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. Methods We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity. Results Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01). Conclusions Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively. Level of Evidence Level I.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - An Liu
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Dongcai Hu
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Deting Xue
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Chao Li
- Department of Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Kai Zhang
- Department of Nuclear Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Honghai Ma
- Department of Thoracic surgery, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Shigui Yan
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Zhijun Pan
- Department of Orthopedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- * E-mail:
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Bjerregaard LS, Bogø S, Raaschou S, Troldborg C, Hornum U, Poulsen AM, Bagi P, Kehlet H. Incidence of and risk factors for postoperative urinary retention in fast-track hip and knee arthroplasty. Acta Orthop 2015; 86:183-8. [PMID: 25301436 PMCID: PMC4404768 DOI: 10.3109/17453674.2014.972262] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Postoperative urinary retention (POUR) is a clinical challenge, but there is no scientific evidence for treatment principles. We describe the incidence of and predictive factors for POUR in fast-track total hip (THA) and knee arthroplasty (TKA). PATIENTS AND METHODS This was a prospective observational study involving 1,062 elective fast-track THAs or TKAs, which were performed in 4 orthopedics departments between April and November 2013. Primary outcome was the incidence of POUR, defined by postoperative catheterization. Age, sex, anesthetic technique, type of arthroplasty, and preoperative international prostate symptom score (IPSS) were compared between catheterized and non-catheterized patients. RESULTS The incidence of POUR was 40% (range between departments: 30-55%). Median bladder volume evacuated by catheterization was 0.6 (0.1-1.9) L. Spinal anesthesia increased the risk of POUR (OR = 1.5, 95% CI: 1.02-2.3; p = 0.04) whereas age, sex, and type of arthroplasty did not. Median IPSS was 6 in non-catheterized males and 8 in catheterized males (p = 0.02), but it was 6 in the females in both groups (p = 0.4). INTERPRETATION The incidence of POUR in fast-track THA and TKA was 40%, with spinal anesthesia and increased IPSS in males as predictive factors. The large variation in perioperative bladder management and in bladder volumes evacuated by catheterization calls for randomized studies to define evidence-based principles for treatment of POUR in the future.
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Affiliation(s)
- Lars S Bjerregaard
- Section for Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Denmark.,The Lundbeck Foundation Center for Fast-track Hip and Knee Replacement. Department of Orthopaedics, at
| | | | | | | | | | - Alicia M Poulsen
- Department of Urology, Rigshospitalet, Copenhagen University, Denmark
| | - Per Bagi
- Department of Urology, Rigshospitalet, Copenhagen University, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Denmark.,The Lundbeck Foundation Center for Fast-track Hip and Knee Replacement. Department of Orthopaedics, at
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Huang Z, Ma J, Shen B, Pei F. General anesthesia: to catheterize or not? A prospective randomized controlled study of patients undergoing total knee arthroplasty. J Arthroplasty 2015; 30:502-6. [PMID: 25307883 DOI: 10.1016/j.arth.2014.09.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/05/2014] [Accepted: 09/23/2014] [Indexed: 02/01/2023] Open
Abstract
This study was to investigate whether urinary catheterization could be avoided for patients undergoing total knee arthroplasty (TKA) under general anesthesia with saphenous nerve block. 314 patients from a single surgical team were randomized to receive either an indwelling urinary catheter or no urinary catheter before the surgery. The results revealed that the prevalence of postoperative urinary retention (POUR) was quite low in both groups (5.7% vs 6.4%, P=1). Additionally, the prevalence of urinary tract infection was significantly higher in patients using an indwelling catheter (5.1% vs 0.6%, P=0.036). We also identified age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of surgery as the risk factors for POUR in these patients.
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Affiliation(s)
- ZeYu Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jun Ma
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Bin Shen
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - FuXing Pei
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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