Seasonal Influence on Postoperative Complications after Total Knee Arthroplasty

The Association of Season of Surgery and Patient Reported Outcomes following Total Hip Arthroplasty

Background

Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA). Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience. The aim of this study is to investigate if there are differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season of the index procedure to improve surgeon preoperative counseling.

Methods

A retrospective chart review was performed on patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographic, operative, hospital, and PROMs were gathered from the institutional electronic medical record and our institutional joint replacement outcomes database.

Results

6418 patients underwent primary THA and met inclusion criteria. Of this patient population, 1636 underwent surgery in winter, 1543 in spring, 1811 in summer, and 1428 in fall. PROMs were equivalent across seasons at nearly time points. The average age of patients was 65 (+/- 10) years, with an average BMI of 29.3 (+/- 6). Rates of complications including ED visits within 30 days, readmission within 90 days, unplanned readmission, dislocation, fracture, or wound infection were not significantly different by season (P > .05).

Conclusion

Our findings indicate no differences in complications and PROMs at 1 year in patients undergoing THA during 4 distinct seasons. Notably, patients had functional differences at the second follow-up visit, suggesting variation in short-term recovery. Patients could be counseled that they have similar rates of complications and postoperative recovery regardless of season.

The Impact of Month on Joint Arthroplasty In-Hospital Outcomes: The December Effect

Background

The purpose of this study was to assess the impact of month of the year on postsurgical outcomes after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to specifically analyze for a December effect.

Material and methods

The National Inpatient Sample was used to identify all patients older than 40 years undergoing primary TKA and THA between 2006 and 2015. Patients were stratified based on the month of the year of surgery. In-hospital complication, disposition, and economic outcomes were comparatively analyzed.

Results

There were statistically significant differences in outcomes based on month of the year. When comparing December to the other months, both TKA and THA patients had significantly lower rates of any complication, postoperative anemia, and genitourinary complications, while there were significantly higher rates of home than rehab discharge and shorter average length of stay in December. THA patients additionally had significantly lower rates of cardiac and respiratory complications during December.

Conclusion

Postoperative outcomes are significantly associated with the month in which arthroplasty is performed. This study provides evidence of a positive "December effect" of improved in-hospital complications and economic outcomes for surgeries performed in December. Future research should direct attention to the impact that social factors may have on outcomes after elective surgical procedures and how these factors may be translated to other months.

Seasonality in surgical outcome data: a systematic review and narrative synthesis

BACKGROUND

Seasonal trends in patient outcomes are an under-researched area in perioperative care. This systematic review evaluates the published literature on seasonal variation in surgical outcomes worldwide.

METHODS

MEDLINE, Embase, Cochrane, CINHAL, and Web of Science were searched for studies on major surgical procedures, examining mortality or other patient-relevant outcomes, across seasonal periods up to February 2019. Major surgery was defined as a procedure requiring an overnight stay in an inpatient medical facility. We included studies exploring variation according to calendar and meteorological seasons and recurring annual events including staff turnover. Quality was assessed using an adapted Downs and Black scoring system.

RESULTS

The literature search identified 82 studies, including 22 210 299 patients from four continents. Because of the heterogeneity of reported outcomes and literature scope, a narrative synthesis was undertaken. Mass staff changeover was investigated in 37 studies; the majority (22) of these did not show strong evidence of worse outcomes. Of the 47 studies that examined outcomes across meteorological or calendar seasons, 33 found evidence of seasonal variation. Outcomes were often worse in winter (16 studies). This trend was particularly prominent amongst surgical procedures classed as an 'emergency' (five of nine studies). There was evidence for increased postoperative surgical site infections during summer (seven of 12 studies examining this concept).

CONCLUSION

This systematic review provides tentative evidence for an increased risk of postoperative surgical site infections in summer, and an increased risk of worse outcomes after emergency surgery in winter and during staff changeover times.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42019137214.

Clinical outcomes of two-stage revision for chronic periprosthetic joint infection of the knee: culture-negative versus culture-positive

Background

The effect of negative culture on the treatment outcomes of chronic periprosthetic joint infection (PJI) is still controversial. The purpose of this study is to evaluate whether the outcomes of two-stage revision in culture-negative chronic PJI differ from those in culture-positive PJI.

Methods

The patients who received two-stage revisions due to chronic PJI during the period between 2007 and 2017 were retrospectively reviewed. The culture-negative and culture-positive PJI group included 57 cases and 79 cases, respectively. The demographic data, as well as reoperation, mortality, reinfection, and failure rates of each group were evaluated.

Results

There was a significant difference in reoperation rate between the two groups for the period from the first-stage surgery to the second-stage revision arthroplasty (p = 0.045). The reoperation rate of the culture-positive group was 25.3% (20/79) whereas that of the culture-negative group was 10.5% (6/57). Among the 136 PJI cases, 97 cases (71.3%) received reimplantation surgery (culture-negative group, 43 cases; culture-positive group, 54 cases). No significant difference was noted between the culture-negative and culture-positive groups with respect to the number of cases that did not undergo reimplantation surgery and the reoperation, reinfection, mortality, and failure rates after two-stage surgery (p > 0.05, all parameters).

Conclusions

The culture outcome had no significant effect on the outcome of the two-stage revision in patients with chronic PJI. The reoperation rate after first-stage surgery was significantly higher in the culture-positive group, but the overall failure rate did not significantly differ in both the groups. The presence of a negative culture might be a good prognostic factor for chronic PJI.

Warm Weather and Surgical Site Infections: A Meta-analysis

Seasonal variability, in terms of warm weather, has been demonstrated to be a significant risk factor for surgical site infections (SSIs). However, this remains an underexposed risk factor for SSIs, and many clinicians are not aware of this. Therefore, a systematic review and meta-analysis has been conducted to investigate and quantify this matter.

METHODS

Articles were searched in Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar, and data were extracted from relevant studies. Meta-analysis used random effects models to estimate and compare the pooled odds ratios (OR) and corresponding confidence intervals (CIs) of surgery performed during the warmest period of the year and the colder period of the year.

RESULTS

The systematic review included 20 studies (58,599,475 patients), of which 14 studies (58,441,420 patients) were included for meta-analysis. Various types of surgical procedures across different geographic regions were included. The warmest period of the year was associated with a statistically significant increase in the risk of SSIs (OR 1.39, 95%CI: [1.34-1.45], P < 0.0001). Selection of specific types of surgical procedures (eg, orthopedic or spinal surgery) significantly altered this increased risk.

CONCLUSIONS

The current meta-analysis showed that warm weather seasons are associated with a statistically significant risk increasement of 39% in developing SSIs. This significant risk factor might aid clinicians in preoperative patient information, possible surgical planning adjustment for high risk patients, and potentially specific antibiotic treatments during the warmer weather seasons that could result in decrease of SSIs.

Complications after scrotal surgery - still a major issue?

OBJECTIVE

Gold standard treatment of symptomatic hydrocele or spermatocele is surgery. Despite a minor procedure, complications such as bleeding and infections leading to reoperations may be devastating for the patients. In autumn 2018, an accumulation of complications was seen in our department. The aim of this study was to investigate the rate and grade of complications and to identify potential means to reduce these.

MATERIALS AND METHODS

Patient records of all patients undergoing surgical repair of hydrocele or spermatocele from December 2017 to November 2018 were examined. Results were audited to identify potential causes of complications. The focus was on the perioperative hemostasis and postoperative activity restrictions. The outcome was compared to a consecutive patient series operated the following year.

RESULTS

Sixty-five men were operated on during the first period. Twenty-two patients contacted the department postoperatively due to swelling or pain, 19 patients were examined at the hospital and six patients were re-operated 1-9 times. The following year, 69 patients were operated on. Of these, 16 patients contacted the department postoperatively (p = 0.17), 13 patients were examined at the hospital, and five patients were re-operated (p = 0.68). There was the same complication rate in patients operated by specialist urologists or supervised younger doctors. However, patients preoperatively examined and informed by a specialized urologist had significantly fewer complications compared to those informed by urological residents and interns (p = 0.012).

CONCLUSION

Despite the change in patient information and increased awareness of possible complications, a high proportion of patients still were in need of unplanned contact to the department and reoperation.

Surgeon-stratified cohort analysis of 1976 cementless Zweymüller total hip arthroplasties from a single hospital with 23,255 component years of follow-up

INTRODUCTION

The third-generation Zweymüller hip endoprosthesis has been used for decades with excellent results in arthroplasty registries, but surgeon-stratified reports on this implant are still scarce. The aim of the presented single-hospital cohort analysis of the third-generation Endoplus-Zweymüller primary total hip arthroplasty was to determine implant survival rates until the first revision/removal at 10/15/20/25 years after implantation and to find out whether implant survival depended on the operating surgeon, patient's age and gender, operated side (right/left), season of the year and the set of implanted components (SL-PLUS femur, BICON-PLUS acetabulum or both components).

MATERIALS AND METHODS

The retrospective observational cohort study included 1976 consecutive patients with primary BICON/SL-PLUS Zweymüller hip endoprosthesis implanted at the same operating theater block of the University Medical Centre Ljubljana, Department of Orthopaedic Surgery (Ljubljana, Slovenia) between January 1, 1993 and May 1, 2014. Survival analyses were performed with the Kaplan-Meier method and the Cox regression analysis after minimum 5 and maximum 26 years of follow-up.

RESULTS

At 10/15/20/25 years after implantation, the cumulative proportion of revision-free surviving Zweymüller total hip endoprostheses was 92/90/85/81% and the cumulative proportion with unremoved immobile components was 93/91/87/84%, respectively. After adjustment for age, gender and operated side, less experienced surgeons (odds ratios 2.34-5.00), season of the year at primary implantation (spring vs. winter odds ratio 1.74) and the use of BICON-PLUS acetabulum with femoral stem from another manufacturer (odds ratio 2.23) were significant risk factors of worse implant survival.

CONCLUSIONS

The study presents the largest published third-generation Zweymüller BICON/SL-PLUS total hip arthroplasty cohort from a single non-developmental hospital with 23,255 component years of observation. Study findings indicate the impact of environmental factors at primary implantation and variability between different surgeons on the long-term implant survival.

Seasonal influence on postoperative hip fracture complications: Retrospective cohort of more than 1000 patients from a tertiary-care university hospital

Background

Hip fractures account for one of the most debilitating conditions affecting the general population amongst the developed and developing nations. Investigators aimed to study the influence of the ongoing season i.e. whether patients operated upon in summer or winter, on post-operative complications occurring within 30 days of surgical procedure for hip fractures at a tertiary care hospital and level 1 trauma center.

Materials and methods

Investigators conducted a non-funded, non-commercialized retrospective cohort of 1045 patients with hip fractures managed surgically. Primary exposure was surgical procedures undertaken during the summer months (April–September). Our primary outcome was determining post-operative complication rates from January 2010 to December 2018 and evaluating impact of the season through univariate and multivariable regression analyses using Cox Proportional Hazard Algorithm with STATA V15. The work has been reported in line with the STROCSS criteria.

Results

Age, ASA status, type of procedure, mechanism of injury and Charlson Comorbidity Index (CCI) were identified as significant associated factors with postoperative complications after hip fracture surgery. Although overall results revealed a rising rate of complications during the summer season with a relative risk (RR; 95% CI) of 1.1(0.89–1.32), univariate and multivariable analysis did not show any significant correlations.

Conclusions

The results of this study did not demonstrate a significant seasonal variability in the rate of postoperative complications for hip fracture patients operated upon during the hot months of summer. More research is required to analyze postoperative complications in order to optimize patients’ outcomes.

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The number of hip fractures has been observed to double as the population ages.

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Surgical management is the gold standard and most effective management option.

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Operating patients during summer is postulated to carry higher risk of postoperative complications.

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However, this higher risk was statistically insignificant in the current study.

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg

INTRODUCTION

Post-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if "seasonality" was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures.

MATERIALS AND METHODS

This retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September-May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression.

RESULTS

A total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096).

CONCLUSIONS

No seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence.