Optimizing perioperative management of total joint arthroplasty

Routine Prescription of Proton Pump Inhibitors in the Perioperative Period is Associated with Decreased Rates of 2-Year Revision Surgery after Total Hip and Knee Arthroplasty

INTRODUCTION

Proton Pump Inhibitors (PPIs) are often prescribed in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) after total hip (THA) and total knee arthroplasty (TKA) due to their gastroprotective effects. In animal studies, it has been suggested that PPIs have immunosuppressive effects and impair fracture healing, however, the association between PPI use and adverse events following THA and TKA has not been well studied.

METHODS

An administrative claims database was queried for patients who underwent elective THA from 2010 to 2019. The experimental group consisted of patients who did not have a prior history of gastrointestinal (GI) bleeding or gastroesophageal reflux disease (GERD) and who received a PPI prescription in the perioperative period. A 1:1 propensity score matching was used to create control cohorts of patients who did not have any PPI prescription filled, also matching for age, sex, and Charlson comorbidity index. This same cohort selection and matching procedure was then repeated for patients undergoing elective TKA. In total, 11,450 patients were studied (3,103 TKA+PPI, 2,622 THA+PPI, 3,103 TKA Controls, and 2,622 THA Controls). The mean age was 64 years (range, 38 to 94), and 57% were women. Significance was considered at P < 0.05.

RESULTS

Perioperative PPI prescription in TKA patients was associated with significantly lower rates of all-cause revision (3.0 versus 4.1%, P < 0.01) and periprosthetic joint infection (1.0 versus 1.8%, P < 0.01). In THA patients, PPI prescription was associated with a lower all-cause revision rate (2.8 versus 4.0%, P = 0.02). No significant differences were found between PPI and non-PPI groups for aseptic loosening, periprosthetic fracture, gastrointestinal bleeding, or surgical site infection in either cohort.

CONCLUSIONS

Patients receiving routine PPI prescriptions in the perioperative period surrounding TKA and THA have a lower risk of all-cause revision surgery, and perioperative PPI use is associated with a decreased risk of PJI in patients undergoing TKA. As these results conflict with the few previous studies performed on this topic, additional controlled studies are warranted to fully elucidate the relationship between PPI use and adverse events after THA and TKA.

Nutritional Considerations in Hip and Knee Arthroplasty: A Critical Analysis of Current Evidence

» Initial screening for malnutrition can be initiated with a fibrinogen-albumin ratio threshold <11.7.» Protein supplementation to goal (1.2-1.9 g/kg), along with essential amino acid augmented with beta-hydroxy-beta-methylbutyrate and resistance training have shown benefit, especially in sarcopenic patients.» Omega-3 and omega-6 polyunsaturated fatty acid supplementation has a strong antioxidant role and gain of muscle mass.» Supplementation with adenosine triphosphate and magnesium sulfate provides an avenue to decrease postoperative pain and opioid consumption.» Motivational interviewing and multidisciplinary teams to achieve preoperative weight loss >20 lbs in morbidly obese patients can decrease complication rates.

[Translated article] Pericapsular nerves block (PENG) is an effective and safe alternative for postoperative pain management after primary total hip arthroplasty: A randomised clinical trial

BACKGROUND

Postoperative pain after total hip arthroplasty can affect postoperative rehabilitation and delay hospital discharge. The objective of this study is to compare pericapsular nerves group (PENG) block with pericapsular infiltration (PAI) and plexus nerve block (PNB) for postoperative pain management, response to physical therapy, opioid consumption, and length of hospital stay after a primary total hip arthroplasty.

METHODS

Randomised clinical trial of parallel and blinded groups was performed. Sixty patients who underwent elective THA between December 2018 and July 2020 were randomised into the different groups (PENG, PAI and PNB). The visual analogue scale was used to assess pain; and motor function was measured with the Bromage scale. We also record opioid usage, length of hospital stay, and related medical complications.

RESULTS

Pain level at discharge was similar in all groups. Hospital stay was 1 day shorter in the PENG group (p<0.001) and they also had lower opioid consumption (p=0.044). Optimal motor recovery was similar in the groups (p=0.678). Pain control when performing physical therapy was better in the PENG group (p<0.0001).

CONCLUSIONS

PENG block is an effective and safe alternative for patients undergoing THA as it reduces opioid consumption and hospital stay compared to other analgesic methods.

Pericapsular nerves block (PENG) is an effective and safe alternative for postoperative pain management after primary total hip arthroplasty: A randomized clinical trial

BACKGROUND

Postoperative pain after total hip arthroplasty can affect postoperative rehabilitation and delay hospital discharge. The objective of this study is to compare pericapsular nerves group (PENG) block with pericapsular infiltration (PAI) and plexus nerve block (PNB) for postoperative pain management, response to physical therapy, opioid consumption, and length of hospital stay after a primary total hip arthroplasty.

METHODS

Randomized clinical trial of parallel and blinded groups was performed. Sixty patients who underwent elective THA between December 2018 and July 2020 were randomized into the different groups (PENG, PAI and PNB). The visual analog scale was used to assess pain; and motor function was measured with the Bromage scale. We also record opioid usage, length of hospital stay, and related medical complications.

RESULTS

Pain level at discharge was similar in all groups. Hospital stay was 1 day shorter in the PENG group (p<0.001) and they also had lower opioid consumption (p=0.044). Optimal motor recovery was similar in the groups (p=0.678). Pain control when performing physical therapy was better in the PENG group (p<0.0001).

CONCLUSIONS

PENG block is an effective and safe alternative for patients undergoing THA as it reduces opioid consumption and hospital stay compared to other analgesic methods.

Hip and Knee Arthroplasty

Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.

Incidence and risk factors for perioperative death after revision total hip arthroplasty: a 20-year analysis

INTRODUCTION

The number of revision total hip arthroplasty (THA) procedures is increasing in the US. Revision THA is associated with higher complication rates compared with primary THA. We describe patterns in incidence and risk factors for perioperative death after revision THA.

METHODS

Using the National Hospital Discharge Survey, we identified nearly 700,000 cases of revision THA from 1990 through 2010. Procedure incidence, perioperative mortality rates, comorbidities, discharge disposition, and duration of hospital stay were analysed. Multivariable logistic regression was used to identify independent risk factors for perioperative death. Alpha = 0.01.

RESULTS

Population-adjusted incidence of revision THA per 100,000 people increased from 9.2 cases in 1990 to 15 cases in 2010 (p < 0.001). The rate of perioperative death was 0.9% during the study period and decreased from 1.5% during the "first" period (1990-1999) to 0.5% during the "second" period (2000-2010) (p < 0.001), despite an increase in comorbidity burden over time. Factors associated with the greatest odds of perioperative death were acute myocardial infarction (odds ratio [OR], 37; 95% confidence interval [CI], 33-40; p < 0.001), pneumonia (OR, 16; 95% CI, 15-18; p < 0.001), and pulmonary embolism (OR, 13; 95% CI, 11-15; p < 0.001).

CONCLUSIONS

The rate of perioperative death in patients undergoing revision THA in the US decreased from 1990 to 2010 despite an increase in comorbidities. Acute myocardial infarction, pneumonia, and pulmonary embolism were associated with the highest odds of perioperative death after revision THA.

Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial

Introduction: Total knee arthroplasty (TKA) is a life-changing joint surgery that improves health-related quality of life and functional status. Patients in need of this surgery mostly belong to the geriatric age group with limited functional reserves and multiple co-morbidities requiring utmost perioperative care with the most suitable analgesic modalities. Regional analgesia (RA) should provide effective analgesia while allowing early mobility, reduced opioid consumption, and early discharge. Dual subsartorial block (DSB) is a novel procedure-specific, motor-sparing, and opioid-sparing RA technique for TKA surgeries. Our study compared the analgesic efficacy of the two different combinations of volumes used in DSB.

Methods: This prospective randomized comparative study included patients between 25-75 years of age of American Society of Anesthesiology (ASA) I-II grades who underwent an elective cemented unilateral total knee replacement performed via medial approaches under neuraxial anesthesia. A total of 104 patients were divided into two equal groups based on the local anesthetic (LA) volumes (Group A 10/20 ml and Group B 20/10 ml) used in the DSB. Postoperative pain scores (using a visual analog scale) and quadriceps strengths (using neurological exam), and opioid consumption were measured at regular intervals till discharge.

Results: Most patients (71.2%) remained pain-free and comfortable until discharge, while 28.8% complained of pain within 12 hours of DSB. Mean quadriceps strength remained almost normal (4-5/5) until the discharge with no incidences of buckling or fall in either group. Over time, the postoperative trend between the groups showed a significant difference for dynamic pain (p = 0.002) and quadriceps strength (p = <0.001). There was an insignificant difference (p = 0.161) between the groups regarding opioid consumption, with the median oral morphine equivalent of zero in both groups. 

Discussion: The effective analgesic coverage of DSB is based on the involvement of all innervations of the procedure-specific pain generators of TKR surgeries. The specific focus on selective sensory innervations and the type/volume of the LA used makes DSB a motor-sparing RA alternative that facilitates early mobility and discharge. It can provide effective postoperative analgesia without compromising the motor strength of the quadriceps muscle when administered in either 10/20 or 20/10 volumes.

Caffeine supplementation as part of enhanced recovery after surgery pathways: a narrative review of the evidence and knowledge gaps

Caffeine is used daily by 85% of United States adults and caffeine withdrawal is a major cause of perioperative headache. Studies have shown that caffeine supplementation in chronic caffeinators reduces the incidence of perioperative headache. This narrative review discusses the perioperative implications of caffeine withdrawal and outlines the benefits of and strategies of caffeine supplementation in the perioperative period. It is time to "wake up and smell the coffee" on integration of caffeine into established enhanced recovery after surgery protocols as a mechanism to consistently provide perioperative caffeine replacement.

Changing practice to increase rates of spinal anaesthesia for total joint replacement

BACKGROUND

Neuraxial anaesthesia for lower extremity total joint replacement surgery has several advantages over general anaesthesia; however, we encountered resistance to routine use of spinal anaesthesia and standardised analgesic regimens at our large, tertiary hospital. Our Perioperative Surgical Home led to multidisciplinary education and enhanced communication to change practice, with the purpose of increasing rates of neuraxial anaesthetics for these surgeries.

METHODS

Team members from anaesthesia, nursing and surgery participated in the development and adoption of the care pathway. After implementation, we performed a retrospective analysis to examine the impact of the pathway on primary anaesthetic choice. Data were analysed using Student's t-test and interrupted time series analysis.

RESULTS

The rate of neuraxial anaesthetics increased following implementation of the total joint pathway.

CONCLUSION

With multidisciplinary collaboration, we were able to change practice towards spinal anaesthesia, despite a large and diverse group of practitioners.

Clinical Pharmacist Service Associated With Improved Outcomes and Cost Savings in Total Joint Arthroplasty

BACKGROUND

Institutions providing total joint arthroplasty (TJA) procedures are subject to substantial outcomes reporting, including those influencing payment for services. Although clinical pharmacists are well-poised to add value, a comprehensive approach to optimizing pharmacotherapy across the care continuum for TJA patients has not been described.

METHODS

This prospective, interventional, sequential cohort study was approved by our Institutional Review Board. The objective was to assess the impact of an Orthopedic Clinical Pharmacist service on institutional TJA complication rates and costs. Outcomes were compared for a Baseline period of July 2015 to February 2016 and a Post-implementation period of September 2016 to February 2017, allowing for a 6-month run-in period. Additionally, we pursued a post-discharge, RN-administered patient survey and an exploratory economic assessment.

RESULTS

A total of 1715 TJA procedures were performed at the institution during the 20-month study timeframe. Postoperative readmission rate (1.3% vs 4.8%, P = .002) and complication rate (1.8% vs 3.4%, P = .760) were lower in the Post-implementation period. Postoperative VTE rate decreased to zero in the Post-implementation period (0.0% vs 0.6%, P = .13) and average hospital length of stay was unchanged (2.8 vs 2.9 days). Patient self-rated understanding of discharge medications was improved and satisfaction with pharmacist interaction was very high. The service conferred an estimated $73,410 net annual cost savings to the institution.

CONCLUSION

Integration of a clinical pharmacist service for TJA patients was associated with clinically meaningful improvements in institutional outcomes, likely conferring substantial cost-benefit.

PT Achievement in Public Hospitals and Its Effect on Outcomes

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

Continuous Posterior Lumbar Plexus Nerve Block Versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Total Hip Arthroplasty: A Three-Arm Randomized Clinical Trial

BACKGROUND

Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI.

METHODS

This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units.

RESULTS

We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication.

CONCLUSIONS

In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Does physical activity change following hip and knee replacement? Matched case-control study evaluating Physical Activity Scale for the Elderly data from the Osteoarthritis Initiative

OBJECTIVES

To determine whether physical activity measured using the Physical Activity Scale for the Elderly (PASE), changes during the initial 24 months post-total hip (THR) or knee replacement (TKR), and how this compares to a matched non-arthroplasty cohort.

DESIGN

Case-controlled study analysis of a prospectively collected dataset.

SETTING

USA community-based.

PARTICIPANTS

116 people post-THR, 105 people post-TKR compared to 663 people who had not undergone THR or TKR, or had hip or knee osteoarthritis. Cohorts were age-, gender- and BMI-matched.

MAIN OUTCOME MEASURES

Physical activity assessed using the 12-item PASE at 12 and 24 months post operatively.

RESULTS

There was no significant difference in total PASE score between pre-operative to 12 months (mean: 136 vs 135 points; p=0.860) or 24 months following THR (mean: 136 vs 132 points; p=0.950). Whilst there was no significant difference in total PASE score from pre-operative to 12 months post-TKR (126 vs 121 points; p=0.930), by 24 months people following TKR reported significantly greater physical activity (126 vs 142 points; p=0.040). There was no statistically significant difference in physical activity between the normative matched and THR (p≥0.140) or TKR (p≥0.060) cohorts at 12 or 24 months post joint replacement.

CONCLUSIONS

Physical activity is not appreciably different to pre-operative levels at 12 or 24 months post-THR, but was greater at 24 months following TKR. Health promotion strategies are needed to encourage greater physical activity participation following joint replacement, and particularly targeting those who undergo THR.

Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients

BACKGROUND

Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care.

METHODS

We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups.

RESULTS

After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%.

CONCLUSION

Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.

Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS.

RESULTS

Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001).

CONCLUSION

Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.

Perioperative Pain Management in Total Hip Arthroplasty: Korean Hip Society Guidelines

Effective perioperative pain management techniques and accelerated rehabilitation programs can improve health-related quality of life and functional status of patients after total hip arthroplasty. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia. Recently, peripheral nerve blockade has emerged alternative analgesic approach. Multimodal analgesia strategy combines analgesics with different mechanisms of action to improve pain management. Intraoperative periarticular injection of multimodal drugs is one of the most important procedures in perioperative pain control for total hip arthroplasty. The goal of this review article is to provide a concise overview of the principles of multimodal pain management regimens as a practical guide for the perioperative pain management for total hip arthroplasty.