Operative Time, Length of Stay, Short-Term Readmission, and Complications after Hinged Primary Total Knee Arthroplasty: A Propensity Score Matched Analysis

AbstractDespite the wide utilization of total knee arthroplasty (TKA), it can be technically challenging to perform in patients who have concomitant bone loss, ligamentous laxity, or high-grade deformity, whether in a revision situation or due to a primary pathology. Therefore, hinged knee prostheses have been developed to provide more stable fixation in these situations. The purpose of this study was to compare the short-term peri- and postoperative outcomes of patients undergoing primary TKA with and without hinged prosthesis. Specifically, we compared (1) mean operative times, (2) lengths of stay (LOS), (3) 30-day readmissions, and (4) complications. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify hinged TKAs and 99 procedures were included. They were matched in a 1:3 ratio to primary TKAs without a hinged prosthesis using propensity score matching. Operative time, LOS, discharge disposition, 30-day readmissions, and complications were compared. Adjusted odds ratios (OR) were also calculated. The operative time was significantly higher in hinged cohort compared with the nonhinged cohort (mean difference [MD] = 22 minutes; range, 10–34 minutes, p < 0.001). There were no significant differences between hinged and nonhinged TKAs with respect to LOS (MD= 0.61 days, range, –0.07–1.30 days, p = 0.080), discharge disposition (OR = 1.09, 95% confidence interval [CI], 0.66–1.84), readmissions (OR = 2.67, 95% CI, 0.84–8.24), and any complications (OR = 1.13, 95% CI, 0.55–2.19). Not surprisingly, primary TKAs with hinged prostheses had increased operative times, but had similar LOS, discharge dispositions, and 30-day rates of readmission and complications when compared with TKAs without a hinged prosthesis. One potential contributing factor to the increased operating time is that patients who receive a hinged implant tend to present with more severe deformities. It is reassuring to know that early outcomes were similar between both cohorts (although we await longer follow-up studies), and that hinged implants can be considered in these difficult to treat patients.

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Efficiency and Blood Loss of Various Spacer and Intramedullary Dowel Constructs in Two-Stage Treatment of Total Knee Arthroplasty

Proceedings of IMPRS ◽

10.18060/23495 ◽

2019 ◽

Vol 2 (1) ◽

Author(s):

Hanna House, BS ◽

Mary Ziemba-Davis, BA ◽

Michael Meneghini, MD

Keyword(s):

Total Knee Arthroplasty ◽

Blood Loss ◽

Knee Arthroplasty ◽

Operative Time ◽

Operating Time ◽

Treatment Protocol ◽

Two Stage ◽

Tourniquet Time ◽

Infected Total Knee Arthroplasty ◽

Total Knee

Background and Hypothesis: Treatment for infected total knee arthroplasty (TKA) employs antibiotic-eluding articulating or static spacers, with or without intramedullary (IM) dowels between implant resection and reimplantation. While it is unknown which spacer type is more efficient intra-operatively, IM dowels require additional time for fabrication. Surgical efficiency is critical to minimizing anesthesia time and blood loss, especially in complex surgeries with compromised hosts. We quantified operative time and postoperative intra-articular blood loss based on spacer type and the use of IM dowels. Project Methods: 103 consecutive infected TKAs treated from 2010-2019 were retrospectively reviewed. Outcome variables included operative time and intraarticular drain rate. Covariates included sex; age, BMI; ASA-PS classification; surgeon; McPherson infection classification; tourniquet time; tranexamic acid (TXA) use; intrathecal anesthesia, length of stay, and blood transfusion. Multivariate analyses were used. Results: The sample was 52% female with average age of 66±9 years and average BMI of 36±9 kg/m2. Articulating spacers without dowels (ASwoD), articulating spacers with dowels (ASwD), and static spacers with dowels were used in 57.3%, 21.4%, and 21.4% of knees, respectively. Longer mean operating time was observed when static spacers with dowels were used at resection (162 vs.130 ASwoD/140 ASwD minutes; p=0.001) and reimplantation (187 vs. 149 ASwoD/148 ASwD minutes; p=0.017). At reimplantation, drain rate was highest when articulating spacers with dowels were used (37 vs. 20/26 mL/hr), but not when TXA was used (p=0.002). Conclusion and Potential Impact: Articulating and static spacers provide equivalent infection eradication, and the necessity of IM dowels has not been thoroughly studied. In light of this equivalency, it is important to understand other costs associated with spacer types and IM dowels. Our observations that spacer/dowel constructs affect time under anesthesia and blood loss may contribute to the efficiency and safety of the two-stage treatment protocol.

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Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis

The Journal of Knee Surgery ◽

10.1055/s-0041-1731323 ◽

2021 ◽

Author(s):

Linsen T. Samuel ◽

Jaret M. Karnuta ◽

Aditya Banerjee ◽

Isaac Briskin ◽

William A. Cantrell ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Propensity Score ◽

Knee Arthroplasty ◽

Operative Time ◽

Robotic Arm ◽

Pain Scores ◽

Randomized Controlled Studies ◽

Patient Reported ◽

Total Knee ◽

Ed Visits

AbstractThe purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal–Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0–13.0] vs. 11.5 [9.5–15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.

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Postoperative Infection in Cementless and Cemented Total Knee Arthroplasty: A Propensity Score Matched Analysis

The Journal of Knee Surgery ◽

10.1055/s-0039-1678678 ◽

2019 ◽

Vol 32 (11) ◽

pp. 1058-1062 ◽

Cited By ~ 2

Author(s):

Hiba K. Anis ◽

Deepak Ramanathan ◽

Nipun Sodhi ◽

Alison K. Klika ◽

Nicolas S. Piuzzi ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Propensity Score ◽

Knee Arthroplasty ◽

Postoperative Infection ◽

Joint Infection ◽

Univariate Analysis ◽

Infection Rates ◽

Related Factors ◽

Primary Tkas ◽

Total Knee

AbstractThe ongoing debate on fixation in total knee arthroplasty (TKA) has become increasingly relevant with its increased use in a younger patient population and the advent of novel cementless prostheses. Recent literature suggests modern cementless implants are comparable to their cemented counterparts in terms of survivorship and functional outcomes. What has not been well-assessed is whether the two modalities differ with respect to infection rates which was the purpose of this study. Specifically, a propensity score matched study population was used to compare: (1) overall infection; (2) prosthetic joint infection (PJI); and (3) surgical site infection (SSI) rates between cementless and cemented TKAs. Using a large institutional database, 3,180 consecutive primary TKAs were identified. Cementless and cemented TKA patients were propensity score matched by age (p = 0.069), sex (p = 0.395), body mass index (BMI; p = 0.308), and Charlson's comorbidity index (CCI) score (p = 0.616) in a 1:1 ratio. Univariate analysis was performed to compare 2-year overall infection rates. Infections were further analyzed separately as PJIs (deep joint infections requiring surgery) and SSIs (skin/superficial wound infections). Multivariate logistic regression was performed to evaluate infection incidences after adjusting for procedure-related factors (i.e., operative time, hospital volume, and surgeon volume). There were no significant differences between the matched cohorts in terms of overall infection rates (3.8 vs. 2.3%, p = 0.722), as well as when PJI (p = 1.000) and SSI (p = 1.000) rates were analyzed separately. Multivariate analysis revealed no significant differences in overall postoperative infection rates (p = 0.285), PJI rates (p = 0.446), or SSI rates (p = 0.453) even after adjusting for procedure-related factors. There is increasing literature investigating various outcomes demonstrating the comparable efficacies of cementless versus cemented TKAs. To the best of the author's knowledge, this was the first matched case-control study to directly compare their post-operative infection rates. The findings from this study show that post-operative infection rates were similar between fixation modalities even after accounting for a range of patient- and procedure-related factors.

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

Canadian Journal of Surgery ◽

10.1503/cjs.002720 ◽

2021 ◽

Vol 64 (3) ◽

pp. E273-E279

Author(s):

Mina W. Morcos ◽

Lauren Nowak ◽

Emil Schemitsch

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Operating Time ◽

Major Complication ◽

Minor Complication ◽

Readmission Rates ◽

Improvement Program ◽

Surgical Time ◽

Total Knee ◽

A Minor

Background: The aim of this study was to evaluate the influence of operating time on complications and readmission within 30 days of total knee arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes. Methods: The American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify patients 18 years of age and older who underwent TKA between 2006 and 2017, using procedural codes. Patient demographic characteristics, operation length and 30-day major and minor complication and readmission rates were captured. We used multivariable regression to determine if the rates of complications and readmission differed depending on the length of the operation, while adjusting for relevant covariables. Results: A total of 263 174 patients who underwent TKA were identified from the database. Their mean age was 66.8 (standard deviation 9.7) years. Within 30 days of the index procedure, 5700 patients (2.2%) experienced a major complication, 5185 (2.0%) experienced a minor complication and 7730 (3.1% of 249 746 patients from 2011 to 2017) were readmitted. Mean operation length was 91.7 minutes (range 30–240 min). After adjustment for relevant covariables, an operating time of 90 minutes or more was a significant predictor of major and minor complications as well as readmission. There was no difference in the odds of complications or readmission for operations lasting 30–49, 50–69 or 70–89 minutes (p > 0.05). Conclusion: Our data suggest that operating times of 90 minutes or more may be associated with an increase in the 30-day odds of complications and readmission following TKA. Further studies are needed to confirm our findings and determine the influence of surgical time on outcomes when there is increased case complexity.

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Trends in Operative Time and Short-Term Outcomes After Conventional and Navigated Total Knee Arthroplasty

Arthroplasty Today ◽

10.1016/j.artd.2021.02.015 ◽

2021 ◽

Vol 8 ◽

pp. 188-193

Author(s):

Troy K. Sekimura ◽

Alexander Upfill-Brown ◽

Peter P. Hsiue ◽

Amir Khoshbin ◽

Erik N. Zeegen ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Operative Time ◽

Short Term ◽

Total Knee

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Surgical Case Order is an Independent Risk Factor for Postoperative Infection in Primary Total Knee Arthroplasty

10.21203/rs.3.rs-751166/v1 ◽

2021 ◽

Author(s):

Dengying Wu ◽

Chao Jia ◽

Hongwei Lu ◽

Shuoyi Zhou ◽

Zheng wu ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Risk Factor ◽

Knee Arthroplasty ◽

Independent Risk Factor ◽

Operative Time ◽

Operating Time ◽

Significant Risk ◽

Surgical Case ◽

Operative Outcomes ◽

Total Knee

Abstract Background: Total knee arthroplasty is regarded as the most effective treatment for severe knee joint problems. Surgery case order influences operative outcomes according to previous studies. This study aims to evaluate the effect of surgical case order on operative outcomes for TKA.Methods: A retrospective study was conducted on 4,267 TKAs performed by three surgeons at our hospital from February 2008 to February 2018. Variables, such as surgical time, loss of blood, and hospitalization stay, were also recorded and analysed. Logistic regression was used to analyse every variable as a potential risk for a surgical site infection.Results: Of the 4267 cases in this cohort, 1531 TKAs were classified as first-round cases, 1194 TKAs were second-round cases, 913 TKAs were third-round cases, 490 TKAs were fourth-round cases, and 139 were fifth-round or later cases. The mean operating time was shorter in intermediate cases (P< 0.01). Perioperative adverse events were increased in later surgical cases (P< 0.01). Later case order (OR= 1.29 [95% CI: 1.17–1.56], P<0.01) was a significant risk factor for severe arthroplasty complications. The operative time and length of stay were increased for cases performed later in the day. However, blood loss is not statistically associated with case order. Conclusions: Surgical case order is an independent risk factor for surgical infection. Significantly increased operative time and longer LOS were noted for third-round or later TKA cases. Our results identify potentially modifiable risk factors contributing to infection rates in TKA, and cases operated on later in the day in the same room were more likely to have a higher infection risk.

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Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018

The Journal of Knee Surgery ◽

10.1055/s-0040-1721414 ◽

2020 ◽

Author(s):

Jared A. Warren ◽

John P. McLaughlin ◽

Robert M. Molloy ◽

Carlos A. Higuera ◽

Jonathan L. Schaffer ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Platelet Count ◽

Knee Arthroplasty ◽

Categorical Variables ◽

Bleeding Disorders ◽

Blood Management ◽

Improvement Program ◽

Preoperative Anemia ◽

High Incidence ◽

Total Knee

AbstractBoth advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 (p < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 (p < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 (p < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 (p < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 (p < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 (p = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.

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Impact of Preoperative Opioid Use on Patient-Reported Outcomes after Revision Total Knee Arthroplasty: A Propensity Matched Analysis

The Journal of Knee Surgery ◽

10.1055/s-0041-1729966 ◽

2021 ◽

Author(s):

Eitan Ingall ◽

Christian Klemt ◽

Christopher M. Melnic ◽

Wayne B. Cohen-Levy ◽

Venkatsaiakhil Tirumala ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Propensity Score ◽

Knee Arthroplasty ◽

Patient Reported Outcomes ◽

Opioid Use ◽

Absolute Increase ◽

Patient Reported ◽

Total Knee ◽

Opioid Users ◽

Revision Tka

AbstractThis is a retrospective study. Prior studies have characterized the deleterious effects of narcotic use in patients undergoing primary total knee arthroplasty (TKA). While there is an increasing revision arthroplasty burden, data on the effect of narcotic use in the revision surgery setting remain limited. Our aim was to characterize the effect of active narcotic use at the time of revision TKA on patient-reported outcome measures (PROMs). A total of 330 consecutive patients who underwent revision TKA and completed both pre- and postoperative PROMs was identified. Due to differences in baseline characteristics, 99 opioid users were matched to 198 nonusers using the nearest-neighbor propensity score matching. Pre- and postoperative knee disability and osteoarthritis outcome score physical function (KOOS-PS), patient reported outcomes measurement information system short form (PROMIS SF) physical, PROMIS SF mental, and physical SF 10A scores were evaluated. Opioid use was identified by the medication reconciliation on the day of surgery. Propensity score–matched opioid users had significantly lower preoperative PROMs than the nonuser for KOOS-PS (45.2 vs. 53.8, p < 0.01), PROMIS SF physical (37.2 vs. 42.5, p < 0.01), PROMIS SF mental (44.2 vs. 51.3, p < 0.01), and physical SF 10A (34.1 vs. 36.8, p < 0.01). Postoperatively, opioid-users demonstrated significantly lower scores across all PROMs: KOOS-PS (59.2 vs. 67.2, p < 0.001), PROMIS SF physical (43.2 vs. 52.4, p < 0.001), PROMIS SF mental (47.5 vs. 58.9, p < 0.001), and physical SF 10A (40.5 vs. 49.4, p < 0.001). Propensity score–matched opioid-users demonstrated a significantly smaller absolute increase in scores for PROMIS SF Physical (p = 0.03) and Physical SF 10A (p < 0.01), as well as an increased hospital length of stay (p = 0.04). Patients who are actively taking opioids at the time of revision TKA report significantly lower preoperative and postoperative outcome scores. These patients are more likely to have longer hospital stays. The apparent negative effect on patient reported outcomes after revision TKA provides clinically useful data for surgeons in engaging patients in a preoperative counseling regarding narcotic use prior to revision TKA to optimize outcomes.

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