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Deemer AR, Ganta A, Leucht P, Konda S, Egol KA. Regional Anesthesia Is Safe and Effective for Low-Energy Tibial Plateau Fractures. Orthopedics 2023; 46:358-364. [PMID: 37052595 DOI: 10.3928/01477447-20230407-02] [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: 04/14/2023]
Abstract
The purpose of this study was to determine if the use of peripheral nerve blocks in the operative management of tibial plateau fractures is associated with improved outcomes when compared with the use of spinal and general anesthesia. Over a period of 16 years, 132 patients who underwent operative repair for a low-energy tibial plateau fracture and had at least 12 months of follow-up met the inclusion criteria and formed the basis of this study. Patients were grouped into cohorts based on the anesthetic method used during surgery: peripheral nerve block in combination with conscious sedation or general anesthesia (BA), general anesthesia alone (GA), or spinal anesthesia alone (SA). Outcomes were assessed at 3 months, 6 months, and 12 months. Length of stay was greatest in the GA cohort (P<.05), and more patients in the BA cohort were discharged to home (P<.05). Patients in the GA cohort had the highest pain scores at 3 months and 6 months (P<.05). Patients in both the SA and BA cohorts had better Short Musculoskeletal Function Assessment scores at 6 and 12 months when compared with the GA cohort (P<.05). Although knee range of motion did not differ among the three cohorts at 3 months, it did differ at 6 months and 12 months postoperatively, with those who had a preoperative nerve blockade (SA and BA) having the greatest knee range of motion (P<.05). Regional anesthesia was safe and was associated with lower pain scores in the early postoperative period and greater knee range of motion and functional outcome scores in the late postoperative period. [Orthopedics. 2023;46(6):358-364.].
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Shah KC, Poeran J, Zubizarreta N, McCardle K, Jebakumar J, Moucha CS, Hayden BL. Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study. Knee 2022; 38:36-41. [PMID: 35907329 PMCID: PMC9125170 DOI: 10.1016/j.knee.2022.05.004] [Citation(s) in RCA: 2] [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: 02/21/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND After the suspension of elective surgeries was lifted in June 2020 in New York State, challenges remained regarding coordination of total joint arthroplasty (TJA) cases. Using the experience from a high-volume health system in New York City, we aimed to describe patterns of care after resumption of elective TJA. METHODS We retrospectively assessed 7,699 TJAs performed before and during the COVID-19 pandemic. Perioperative characteristics and clinical outcomes were compared between TJAs based on time period of performance: 1) pre-pandemic (PP, June 8th-December 8th, 2019), 2) initial period post-resumption of elective surgeries (IR, June 8th-September 8th, 2020), and 3) later period post-resumption (LR, September 9th-December 8th, 2020). RESULTS LOS > 2 days (83%, 67%, 70% for PP, IR, LR periods respectively) and discharge rates to post-acute care (PAC) facilities were lower during the pandemic periods (ORIR vs. PP: 0.48, 95% CI: 0.40-0.59, p < 0.001; ORLR vs. PP: 0.63, 95% CI: 0.53-0.75, p < 0.001). Compared to the pre-pandemic period, the risk for 30-day readmission was lower during the IR period (OR: 0.62, 95% CI: 0.40-0.98, p = 0.041) and similar during the LR period (OR: 0.96, 95% CI: 0.65-1.41, p = 0.832). CONCLUSIONS Despite decreased LOS and discharge to PAC for TJAs performed during the pandemic, 30-day readmissions did not increase. Given the increased costs and lack of superior functional outcomes associated with discharge to PAC, these findings suggest that discharge to PAC facilities need not return to pre-pandemic levels.
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Affiliation(s)
- Kush C. Shah
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ken McCardle
- Department of Clinical Operations, Mount Sinai Health System, USA
| | - Jebakaran Jebakumar
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Calin S. Moucha
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brett L. Hayden
- Department of Orthopedic Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Corresponding author at: Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai Complex, Primary, & Revision Total Joint Replacement and Musculoskeletal Oncology, 5 East 98th St, New York, NY 10029, USA
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Discharge Destination After Shoulder Arthroplasty: An Analysis of Discharge Outcomes, Placement Risk Factors, and Recent Trends. J Am Acad Orthop Surg 2021; 29:e969-e978. [PMID: 33323680 DOI: 10.5435/jaaos-d-20-00294] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/12/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Rates of shoulder arthroplasty continue to increase. Factors influencing disposition and the effect discharge destination may have on perioperative outcomes are currently unknown. This study (1) investigates patients undergoing total shoulder arthroplasty subsequently discharged to home, skilled nursing facilities, and or independent rehabilitation facilities; (2) identifies differences in perioperative outcomes; and (3) investigates the risk of adverse events and readmission after nonhome disposition. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing total shoulder arthroplasty from 2013 to 2018. Bivariate and multivariate analyses were conducted to determine the relationship between patient characteristics and risks of discharge to a non-home destination, discharge to an independent rehabilitation facility as opposed to a skilled nursing facility, severe postdischarge adverse events, and unplanned readmission. RESULTS Factors associated with discharge to a non-home facility included those older than 85 years of age (odds ratio [OR], 14.38), dialysis requirement (OR, 4.16), transfer from a non-home facility (OR, 3.69), dependent functional status (OR, 3.17), female sex (OR, 2.78), history of congestive heart failure (2.05), American Society of Anesthesiologists class >2 (OR, 1.97), longer length of stay (OR, 1.47), and body mass index >35 (OR, 1.29) (P < 0.05). Patients discharged to a non-home facility had an approximately quadrupled rate of both major adverse events (8.6% vs 2.4%, P < 0.001) and minor adverse events (6.1% vs 1.4%, P < 0.001). Discharge to a non-home facility had a higher likelihood of a severe adverse event (OR, 1.82, P = 0.029) or unplanned readmission (OR, 1.60, P = 0.001). CONCLUSIONS Non-home discharge destination demonstrated a notable negative impact on postoperative outcomes independent of medical complexity. Preoperative management of modifiable risk factors may decrease length of inpatient stay, rates of disposition to non-home facilities, and total cost of care. The benefit of more intense postoperative management at a non-home discharge destination must be carefully weighed against the independent risk of postoperative adverse events and readmissions.
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Webb ML, Hutchison CE, Sloan M, Scanlon CM, Lee GC, Sheth NP. Reduced postoperative morbidity in computer-navigated total knee arthroplasty: A retrospective comparison of 225,123 cases. Knee 2021; 30:148-156. [PMID: 33930702 DOI: 10.1016/j.knee.2020.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/19/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is one of the most common elective surgical procedures in the United States, with more than 650,000 performed annually. Computer navigation technology has recently been introduced to assist surgeons with planning, performing, and assessing TKA bone cuts. The aim of this study is to assess postoperative complication rates after TKA performed using computer navigation assistance versus conventional methods. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for unilateral TKA cases from 2008 to 2016. The presence of the CPT modifier for use of computer navigation was used to separate cases of computer-navigated TKA from conventional TKA. Multivariate and propensity-matched logistic regression analyses were performed to control for demographics and comorbidities. RESULTS There were 225,123 TKA cases included; 219,880 were conventional TKA (97.7%) and 5,243 were navigated (2.3%). Propensity matching identified 4,811 case pairs. Analysis demonstrated no significant differences in operative time, length of stay, reoperation, or readmission, and no differences in rates of post-op mortality at 30 days postoperatively. Compared to conventional cases, navigated cases were at lower risk of serious medical morbidity (18% lower, p = 0.009) within the first 30 days postoperatively. CONCLUSION After controlling for multiple known risk factors, navigated TKA patients demonstrated lower risk for medical morbidity, predominantly driven by lower risk for blood transfusion. Given these findings, computer-navigation is a safe surgical technique in TKA.
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Affiliation(s)
- Matthew L Webb
- University of Pennsylvania, Department of Orthopaedic Surgery, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Catherine E Hutchison
- University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Matthew Sloan
- University of Pennsylvania, Department of Orthopaedic Surgery, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Christopher M Scanlon
- University of Pennsylvania, Department of Orthopaedic Surgery, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
| | - Gwo-Chin Lee
- University of Pennsylvania, Department of Orthopaedic Surgery, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Neil P Sheth
- University of Pennsylvania, Pennsylvania Hospital, Department of Orthopaedic Surgery, 800 Spruce Street, 8th Floor Preston Building, Philadelphia, PA 19107, USA
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CORR® International-Asia-Pacific: Closing the Loop-Focus Early and Often on Your Patients' Postsurgical Rehabilitation Program. Clin Orthop Relat Res 2020; 478:2225-2227. [PMID: 32898042 PMCID: PMC7491881 DOI: 10.1097/corr.0000000000001475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Koh IJ, Kang BM, Kim MS, Choi KY, Sohn S, In Y. How Does Preoperative Central Sensitization Affect Quality of Life Following Total Knee Arthroplasty? J Arthroplasty 2020; 35:2044-2049. [PMID: 32362478 DOI: 10.1016/j.arth.2020.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/25/2020] [Accepted: 04/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Central sensitization (CS) has been recently identified as a significant risk factor for persistent pain and patient dissatisfaction following total knee arthroplasty (TKA). However, it remains unclear as to whether the preoperative CS persists after the elimination of a nociceptive pain source by TKA, or how CS affects the quality of life after TKA. METHODS A total of 222 consecutive patients undergoing primary TKA were enrolled in the study. All patients were preoperatively screened for CS using the Central Sensitization Inventory (CSI) and categorized into either a CS (n = 55; CSI ≥ 40) or non-CS group (n = 167; CSI < 40). CSI, pain visual analog scale (VAS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score, and satisfaction were recorded at postoperative 2 years. RESULTS Two years after TKA, preoperative CS remained unchanged; there was no difference between preoperative and postoperative CSI scores, and both preoperative and postoperative CSI severity levels were similar (P > .1). The CS group showed worse pain VAS, KSS, and Western Ontario and McMaster Universities Osteoarthritis Index scores than did the non-CS group (P < .01) and more patients in the CS group were dissatisfied with all activities (P < .01). However, a similar percentage of the CS group achieved the previously documented minimal clinically important difference in pain VAS and KSS, compared with the non-CS group. Multivariate regression analysis revealed that preoperative CSI scores were associated with dissatisfaction at postoperative 2 years. CONCLUSION Preoperative CS was persistent at 2 years after TKA. Although CS patients achieved comparable clinical improvement following TKA, CS patients had worse quality of life, functional disability, and dissatisfaction than non-CS patients.
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Affiliation(s)
- In Jun Koh
- Joint Replacement Center, Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea; Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Min Kang
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Man Soo Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Keun Young Choi
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Sueen Sohn
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
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Knapp P, Weishuhn L, Pizzimenti N, Markel DC. Risk factors for manipulation under anaesthesia after total knee arthroplasty. Bone Joint J 2020; 102-B:66-72. [DOI: 10.1302/0301-620x.102b6.bjj-2019-1580.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment. Methods Prospectively collected data of TKAs performed at our institution’s two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA. Results Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°). Conclusion Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons’ decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: Bone Joint J 2020;102-B(6 Supple A):66–72.
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Affiliation(s)
- Paul Knapp
- Ascension Providence Hospital Orthopaedic Residency, Novi, Michigan, USA
| | - Luke Weishuhn
- Beaumont Hospital Orthopedic Residency, Farmington Hills, Michigan, USA
| | | | - David C. Markel
- Ascension Providence Hospital Orthopaedic Residency, Novi, Michigan, USA
- The Core Institute, Novi, Michigan, USA
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Bhagat R, Bronsert MR, Henderson WG, Scott CD, Weyant MJ, Mitchell JD, Fullerton DA, Meguid RA. Analysis of Discharge Destination After Open Versus Minimally Invasive Surgery for Lung Cancer. Ann Thorac Surg 2020; 109:375-382. [DOI: 10.1016/j.athoracsur.2019.08.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/28/2019] [Accepted: 08/19/2019] [Indexed: 12/18/2022]
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Edwards D, Anderson A, Pleus MR, Smith JB, Nguyen JT. Factors Affecting Discharge Disposition After Primary Simultaneous Bilateral Joint Arthroplasty. HSS J 2019; 15:254-260. [PMID: 31624481 PMCID: PMC6778168 DOI: 10.1007/s11420-019-09701-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Predicting discharge destination following total joint arthroplasty (TJA) is important, as discharge destination has major implications for post-operative costs, clinical outcomes, and readmissions. Few studies have looked at factors affecting discharge destination for patients following primary simultaneous bilateral total joint arthroplasty. QUESTIONS/PURPOSES The purpose of this study was to describe clinical and social factors that relate to a discharge to home versus rehabilitation facility (RF) for patients after primary simultaneous bilateral total hip arthroplasty (PSBTHA) or primary simultaneous bilateral total knee arthroplasty (PSBTKA). METHODS The inclusion criteria for this retrospective cohort study were all patients after PSBTHA or PSBTKA at a metropolitan orthopedic specialty hospital between February 1, 2016, and March 31, 2018. Exclusion criteria were revisions, differing weight-bearing status, bed-rest orders, and non-standard hip precautions. Social and clinical demographic data were collected. Multiple regression analysis was conducted to determine which factors related most to discharge plan. RESULTS Of 253 PSBTHA patients, 153 were discharged home and 100 to an RF. Regression analysis found a posterolateral approach to be the only significant factor associated with an RF discharge. Of 619 PSBTKA patients, 136 were discharged home and 483 to RF. Increased body mass index and older age increased the likelihood of discharge to an RF. Patients with an adductor-only nerve block were more likely to be sent to RF. CONCLUSION These findings shed light on the variables that contribute to discharge destination after PSBTHA and PSBTKA. Such information allows for safe pre-operative discharge planning and assists with discharge to the appropriate level of patient care. Future studies might investigate the effect of surgeon experience, surgical technique, and pre-operative discussion with a physical therapist on the discharge disposition of patients undergoing bilateral total joint arthroplasty.
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Affiliation(s)
- Danielle Edwards
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Allison Anderson
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Michael R. Pleus
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jerome B. Smith
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Joseph T. Nguyen
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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