Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients

Abstract Background The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes. Methods Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial–general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes. Results Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial–general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial–general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08–3.1, P = 0.02; OR of 1.70, 95% CI 1.06–2.74, P = 0.02, respectively). Conclusions The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.

Download Full-text

Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2021-103189 ◽

2022 ◽

pp. rapm-2021-103189

Author(s):

Edward Yap ◽

Julia Wei ◽

Christopher Webb ◽

Kevin Ng ◽

Matthias Behrends

Keyword(s):

Cohort Study ◽

General Anesthesia ◽

Knee Arthroplasty ◽

Total Joint Arthroplasty ◽

Outpatient Surgery ◽

Joint Arthroplasty ◽

Neuraxial Anesthesia ◽

General Anesthesia Group ◽

Increased Risk ◽

Same Day Discharge

BackgroundNeuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given the selection of healthier patients.ObjectiveTo compare the effects of neuraxial versus general anesthesia on outcomes following ambulatory hip and knee arthroplasty.MethodsMulticentered retrospective cohort study in ambulatory hip or knee arthroplasty patients between January 2017 and December 2019. Primary endpoint examined 30-day major postoperative complications (mortality, myocardial infarction, deep venous thromboembolism, pulmonary embolism, stroke, and acute renal failure).ResultsOf 11 523 eligible patients identified, 10 003 received neuraxial anesthesia, while 1520 received general anesthesia. 30-day major complications did not differ between neuraxial anesthesia and general anesthesia groups (1.8% vs 2.3%; aOR=0.85, CI: 0.56 to 1.27, p=0.39). There was no difference in 30-day minor complications (surgical site infection, pneumonia, urinary tract infection; 3.3% vs 4.1%; aOR=0.83, CI: 0.62 to 1.14, p=0.23). The neuraxial group demonstrated reduced pain and analgesia requirements and had less postoperative nausea and vomiting (PONV). Median recovery room length of stay was shorter by 52 min in the general anesthesia group, but these patients were more likely to fail same day discharge (33% vs 23.4%; p<0.01).ConclusionAnesthesia type was not associated with an increased risk for complications. However, neuraxial anesthesia improved outcomes that predict readiness for discharge: patients had less pain, required less opioids, and had a lower incidence of PONV, thus improving the rate of same day discharge.Trial registration numberNCT04203732.

Download Full-text

Improving Safety of Bilateral Knee Arthroplasty: Impact of Selection Criteria on Perioperative Outcome

HSS Journal ® ◽

10.1177/15563316211014891 ◽

2021 ◽

pp. 155633162110148

Author(s):

Philipp Gerner ◽

Stavros G. Memtsoudis ◽

Crispiana Cozowicz ◽

Ottokar Stundner ◽

Mark Figgie ◽

...

Keyword(s):

Knee Arthroplasty ◽

Selection Criteria ◽

Perioperative Complications ◽

Perioperative Outcomes ◽

Cardiac Complications ◽

Complication Rates ◽

Major Complications ◽

Increased Risk ◽

Comorbidity Burden ◽

Rate Ratios

Background: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. Questions/Purpose: We sought to investigate the effect of these selection criteria on perioperative outcomes. Methods: In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998–2006) and those who underwent surgery after (2007–2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. Results: Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. Conclusion: After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes.

Download Full-text

Impact of Weight-Band Dosing of Tinzaparin for Venous Thromboembolism Prophylaxis on Persistent Wound Drainage in Adult Patients Undergoing Hip and Knee Arthroplasty

Annals of Pharmacotherapy ◽

10.1177/10600280211024294 ◽

2021 ◽

pp. 106002802110242

Author(s):

Cassandra Cooper ◽

Ouida Antle ◽

Jennifer Lowerison ◽

Deonne Dersch-Mills ◽

Ashley Kenny

Keyword(s):

Body Weight ◽

Venous Thromboembolism ◽

Knee Arthroplasty ◽

Total Joint Arthroplasty ◽

Joint Arthroplasty ◽

Thromboembolism Prophylaxis ◽

Wound Drainage ◽

Increased Risk ◽

Significant Difference ◽

The Impact

Background: Persistent wound drainage and venous thromboembolism (VTE) are potential complications of total joint arthroplasty, and these risks can be challenging to balance in clinical practice. Anecdotal observation has suggested that following joint arthroplasty, persistent wound drainage occurs more frequently with higher body weight and higher doses of tinzaparin when compared with lower body weight and lower doses of tinzaparin. Objective: The overall purpose of this study was to describe the impact of a tinzaparin weight-band dosing table for VTE prophylaxis on wound healing, thrombosis, and bleeding outcomes in patients undergoing total joint arthroplasty. Methods: This retrospective chart review included patients who underwent total hip or knee arthroplasty and received tinzaparin for thromboprophylaxis per their weight-banding category. The primary outcome was the incidence of persistent wound drainage. Secondary outcomes include the occurrence of VTE and clinically important bleeding during hospital admission. Results: A total of 231 patients were included in the analysis. There was no significant difference in persistent wound drainage between the 3 weight categories, and there were no differences in rates of VTE or clinically important bleeding. Concurrent use of low-dose acetylsalicylic acid was associated with a 3-fold increased risk of persistent wound drainage (risk ratio = 3.35; 95% CI = 2.14-5.24; P = 0.00003). Conclusion and Relevance: In joint arthroplasty patients, we observed no significant difference in rates of persistent wound drainage between various weight categories receiving different weight-banded doses of tinzaparin. Our results do not suggest that the current weight-band dosing table for tinzaparin needs to be adjusted to optimize patient outcomes.

Download Full-text

The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty

The Journal of Bone and Joint Surgery (American) ◽

10.2106/jbjs.h.00116 ◽

2009 ◽

Vol 91 (7) ◽

pp. 1621-1629 ◽

Cited By ~ 317

Author(s):

Milford H Marchant ◽

Nicholas A Viens ◽

Chad Cook ◽

Thomas Parker Vail ◽

Michael P Bolognesi

Keyword(s):

Diabetes Mellitus ◽

Glycemic Control ◽

Total Joint Arthroplasty ◽

Joint Arthroplasty ◽

Perioperative Outcomes ◽

The Impact

Download Full-text

Spinal versus general anesthesia for patients undergoing outpatient total knee arthroplasty: a national propensity matched analysis of early postoperative outcomes

BMC Anesthesiology ◽

10.1186/s12871-021-01442-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Mark C. Kendall ◽

Alexander D. Cohen ◽

Stephanie Principe-Marrero ◽

Peter Sidhom ◽

Patricia Apruzzese ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Adverse Events ◽

General Anesthesia ◽

Knee Arthroplasty ◽

Anesthetic Management ◽

Anesthetic Technique ◽

Anesthetic Techniques ◽

Short Term ◽

Knee Replacements ◽

Total Knee

Abstract Background A comparison of different anesthetic techniques to evaluate short term outcomes has yet to be performed for patients undergoing outpatient knee replacements. The aim of this investigation was to compare short term outcomes of spinal (SA) versus general anesthesia (GA) in patients undergoing outpatient total knee replacements. Methods The ACS NSQIP datasets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty (TKA) between 2005 and 2018 performed as an outpatient procedure. The primary outcome was a composite score of serious adverse events (SAE). The primary independent variable was the type of anesthesia (e.g., general vs. spinal). Results A total of 353,970 patients who underwent TKA procedures were identified comprising of 6,339 primary, elective outpatient TKA procedures. Of these, 2,034 patients received GA and 3,540 received SA. A cohort of 1,962 patients who underwent outpatient TKA under GA were propensity matched for covariates with patients who underwent outpatient TKA under SA. SAE rates at 72 h after surgery were not greater in patients receiving GA compared to SA (0.92%, 0.66%, P = 0.369). In contrast, minor adverse events were greater in the GA group compared to SA (2.09%, 0.51%), P < 0.001. The rate of postoperative transfusion was greater in the patients receiving GA. Conclusions The type of anesthetic technique, general or spinal anesthesia does not alter short term SAEs, readmissions and failure to rescue in patients undergoing outpatient TKR surgery. Recognizing the benefits of SA tailored to the anesthetic management may maximize the clinical benefits in this patient population.

Download Full-text

Tourniquet use in routine primary total knee arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a real-world study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03623-5 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Hong Xu ◽

Jingli Yang ◽

Jinwei Xie ◽

Zeyu Huang ◽

Qiang Huang ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Length Of Stay ◽

Knee Arthroplasty ◽

Enhanced Recovery ◽

Primary Total Knee Arthroplasty ◽

Transfusion Rate ◽

Partial Regression Coefficient ◽

Postoperative Length ◽

Total Knee ◽

The Impact

Abstract Background In an enhanced recovery after surgery program, a growing number of orthopedists are reconsidering the necessity of tourniquet use in total knee arthroplasty (TKA). However, the impact of tourniquet use on transfusion rate and postoperative length of stay (PLOS) in TKA remains controversial. Therefore, we carried out a study to investigate the effect of tourniquet application in routine primary TKA on transfusion rate and PLOS. Methods We analyzed data from 6325 patients who underwent primary unilateral TKA and divided them into two groups according to whether a tourniquet was applied during the procedure, and a tourniquet was used in 4902 and not used in 1423. The information for transfusion and PLOS was extracted from patients’ electronic health records, and the data were analyzed with logistic and linear regression analyses. Results Following TKA, the transfusion rate and PLOS were 14.52% and 7.72 ± 3.54 days, respectively, in the tourniquet group, and 6.47% and 6.44 ± 3.48 days, respectively, in the no-tourniquet group. After adjusting for the different related variables, tourniquet use was significantly correlated with a higher transfusion rate (risk ratio = 1.888, 95% confidence interval (CI) 1.449–2.461, P < 0.001) and a longer PLOS (partial regression coefficient (B) = 0.923, 95%CI 0.690–1.156, P < 0.001). Conclusions Our findings suggested that tourniquet use in routine primary TKA was related to a higher transfusion rate and a longer PLOS. The impact of tourniquet use on transfusion rate and PLOS should be taken into account in clinical practice.

Download Full-text

Physiotherapy-led arthroplasty review clinic: a preliminary outcomes analysis

Australian Health Review ◽

10.1071/ah13238 ◽

2014 ◽

Vol 38 (5) ◽

pp. 510 ◽

Cited By ~ 8

Author(s):

Kate E. Large ◽

Carolyn J. Page ◽

Kim Brock ◽

Michelle M. Dowsey ◽

Peter F. M. Choong

Keyword(s):

Outcome Measures ◽

Patient Outcomes ◽

Knee Arthroplasty ◽

Hip Arthroplasty ◽

Short Form ◽

Joint Arthroplasty ◽

Orthopaedic Surgeon ◽

Healthcare Sector ◽

Harris Hip Score ◽

The Impact

Objective With the rising demand for Orthopaedics in the healthcare sector, service delivery innovations need to be explored to accommodate the increasing workload. Senior Musculoskeletal Physiotherapists have the specialised skills in the assessment of musculoskeletal conditions to determine the impact of surgery on patient outcomes. The aim of the present study was to compare outcomes between a physiotherapy-led arthroplasty review clinic (PT clinic) and the traditional model of orthopaedic surgeon review (OS clinic) after hip and knee replacement. Methods This study was a retrospective case-controlled audit using a comprehensive database. Twenty-four patients who had a hip arthroplasty and 52 patients who had a knee arthroplasty were reviewed solely by the PT clinic at 3, 6 and 12 months after surgical reviews. These patients were matched 1 : 2 against patients seen only by the OS clinic. The outcome measures included International Knee Score (IKS), Harris Hip Score (HHS) and the Short Form (SF)-12. Results There were no significant differences in HHS or SF-12 scores for patients after hip arthroplasty. Significant differences for knee arthroplasty were observed favouring the PT clinic; IKS, PT clinic 147.6 (37.07), OS clinic 135.4 (35.68), P ≤ 0.01, and physical component of the SF-12, PT clinic 41.98 (10.45), OS clinic 37.20 (10.44), P < 0.01. Conclusion Implementation of a physiotherapy-led arthroplasty review clinic appears to be a safe and effective service alternative to reviews conducted by orthopaedic surgeons. What is known about the topic? Osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability and the burden of the disease is rapidly increasing. Joint arthroplasty surgery is the mainstay of treatment for people with end-stage OA; it is a high-cost, high-volume procedure that dominates surgical wait lists around Australia. Long-term follow up is encouraged by the Arthroplasty Society of Australia and endorsed by the Australian Orthopaedics Association, but it is acknowledged that it is impossible to achieve this with solely orthopaedic surgeon reviews, an issue that is only going to worsen with the increased demand for surgery. Physiotherapists have become involved in many advanced scope roles within public health care, and emerging research suggests that patients are highly satisfied with their care in these types of clinics. What does this paper add? Although it has been shown that patients are satisfied in physiotherapy-led advanced clinics, there is a paucity of evidence in the outcomes of patients attending these clinics. Implementation of a physiotherapy-led arthroplasty review clinic demonstrated that outcome measures in this patient cohort were not compromised and, following knee joint arthroplasty, may even be improved. What are the implications for practitioners? The findings of this study indicate that joint review clinics involving physiotherapists acting in an advanced scope role are unlikely to compromise patient outcomes. The use of this role substitution on a broader scale can be recommended.

Download Full-text

Open versus minimally invasive decompression for low-grade spondylolisthesis: analysis from the Quality Outcomes Database

Journal of Neurosurgery Spine ◽

10.3171/2020.3.spine191239 ◽

2020 ◽

Vol 33 (3) ◽

pp. 349-359

Author(s):

Erica F. Bisson ◽

Praveen V. Mummaneni ◽

Michael S. Virk ◽

John Knightly ◽

Mohammed Ali Alvi ◽

...

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Perioperative Outcomes ◽

Low Grade ◽

Quality Outcomes ◽

Lumbar Decompression ◽

Patient Reported ◽

Open Versus ◽

The Impact

OBJECTIVELumbar decompression without arthrodesis remains a potential treatment option for cases of low-grade spondylolisthesis (i.e., Meyerding grade I). Minimally invasive surgery (MIS) techniques have recently been increasingly used because of their touted benefits including lower operating time, blood loss, and length of stay. Herein, the authors analyzed patients enrolled in a national surgical registry and compared the baseline characteristics and postoperative clinical and patient-reported outcomes (PROs) between patients undergoing open versus MIS lumbar decompression.METHODSThe authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Among more than 200 participating sites, the 12 with the highest enrollment of patients into the lumbar spine module came together to initiate a focused project to assess the impact of fusion on PROs in patients undergoing surgery for grade I lumbar spondylolisthesis. For the current study, only patients in this cohort from the 12 highest-enrolling sites who underwent a decompression alone were evaluated and classified as open or MIS (tubular decompression). Outcomes of interest included PROs at 2 years; perioperative outcomes such as blood loss and complications; and postoperative outcomes such as length of stay, discharge disposition, and reoperations.RESULTSA total of 140 patients undergoing decompression were selected, of whom 71 (50.7%) underwent MIS and 69 (49.3%) underwent an open decompression. On univariate analysis, the authors observed no significant differences between the 2 groups in terms of PROs at 2-year follow-up, including back pain, leg pain, Oswestry Disability Index score, EQ-5D score, and patient satisfaction. On multivariable analysis, compared to MIS, open decompression was associated with higher satisfaction (OR 7.5, 95% CI 2.41–23.2, p = 0.0005). Patients undergoing MIS decompression had a significantly shorter length of stay compared to the open group (0.68 days [SD 1.18] vs 1.83 days [SD 1.618], p < 0.001).CONCLUSIONSIn this multiinstitutional prospective study, the authors found comparable PROs as well as clinical outcomes at 2 years between groups of patients undergoing open or MIS decompression for low-grade spondylolisthesis.

Download Full-text

Previous History of Breast Cancer Increases Rates of Pulmonary Embolism and Costs after Total Knee Arthroplasty: An Evaluation of 185,114 Matched Patients

The Journal of Knee Surgery ◽

10.1055/s-0038-1641155 ◽

2018 ◽

Vol 32 (04) ◽

pp. 337-343 ◽

Cited By ~ 1

Author(s):

Samuel Rosas ◽

T. Luo ◽

Alexander Jinnah ◽

Alejandro Marquez-Lara ◽

Martin Roche ◽

...

Keyword(s):

Breast Cancer ◽

Pulmonary Embolism ◽

Total Knee Arthroplasty ◽

Length Of Stay ◽

Knee Arthroplasty ◽

Previous History ◽

Increased Risk ◽

Comorbidity Burden ◽

History Of ◽

Total Knee

AbstractRisk factors for adverse events after total knee arthroplasty (TKA) relating to malignancy have not been well studied. Thus, the purpose of this study was to conduct a retrospective case–control outcome and cost analysis after TKA in this population. Patients with a history of breast cancer (BrCa) were identified based on the International Classification of Disease 9th revision codes. An age- and sex-matched cohort was also identified of patients without a history of BrCa. Complications, length of stay, comorbidity burden, and reimbursements were tracked at 90 days. Each cohort comprised 92,557 patients. Length of stay was similar between cohorts (p = 0.627). Comorbidity status and incidence of pulmonary embolism (PE), lower extremity ultrasound, and chest computed tomography (CT) use were higher in patients with a history of BrCa (p < 0.05 for all). Control patients had a lower incidence of acute myocardial infarction (0.14 vs. 0.21%; p < 0.001). Surgical complications were similar. The 90-day reimbursements were greater in patients with a history of BrCa (US$13,990 vs. US$13,033 for controls; p = 0.021). Surgeons should be aware of the increased risk of PE after TKA in patients with a history of BrCa as well as increased 90-day costs, which warrant great attention.

Download Full-text

Risk of Cardiovascular Disease Due to General Anesthesia and Neuraxial Anesthesia in Lower-Limb Fracture Patients: A Retrospective Population-Based Cohort Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17010033 ◽

2019 ◽

Vol 17 (1) ◽

pp. 33

Author(s):

Han-Wei Yeh ◽

Liang-Tsai Yeh ◽

Ying-Hsiang Chou ◽

Shun-Fa Yang ◽

Sai-Wai Ho ◽

...

Keyword(s):

Cardiovascular Disease ◽

General Anesthesia ◽

Lower Limb ◽

Population Based ◽

Neuraxial Anesthesia ◽

Anesthetic Technique ◽

Research Database ◽

Cvd Risk ◽

Limb Fracture ◽

Significant Difference

The purpose of this study was to analyze the relationship between elevated cardiovascular disease (CVD) risk and type of anesthesia by using the National Health Insurance Research Database (NHIRD) of Taiwan in a one-year follow-up period. We assessed whether general anesthesia (GA) or neuraxial anesthesia (NA) increased CVD occurrence in lower-limb fracture patients. Approximately 1 million patients were randomly sampled from the NHIRD registry. We identified and enrolled 3437 lower-limb fracture patients who had received anesthesia during operations conducted in the period from 2010 to 2012. Next, patients were divided into two groups, namely GA (n = 1504) and NA (n = 1933), based on the anesthetic technique received during surgery. Our results revealed that those receiving GA did not differ in their risk of CVD relative to those receiving NA, adjusted HR = 1.24 (95% CI: 0.80–1.92). Patients who received GA for more than 2 h also did not differ in their risk of CVD relative to those receiving NA for less than 2 h, adjusted HR = 1.43 (95% CI: 0.81–2.50). Moreover, in the GA group (i.e., patients aged ≥65 years and women), no significant difference for the risk of CVD events was observed. In conclusion, in our study, the difference in the risk of CVD between lower-limb fracture patients receiving NA and GA was not statistically significant. The incidence rate of CVD seemed to be more correlated with patients’ underlying characteristics such as old age, comorbidities, or admission to the intensive care unit. Due to the limited sample size in this study, a database which reviews a whole national population will be required to verify our results in the future.

Download Full-text