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Veerareddy RR, Panton ZA, Zagaria AB, Lites CJ, Keeney BJ, Werth PM. The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study. J Bone Joint Surg Am 2024; 106:782-792. [PMID: 38502740 DOI: 10.2106/jbjs.23.00465] [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: 03/21/2024]
Abstract
BACKGROUND A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. METHODS We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. RESULTS Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. CONCLUSIONS Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Rakesh R Veerareddy
- Department of Orthopaedics, Dartmouth Health, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Zachary A Panton
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | | | - Benjamin J Keeney
- Berkley Medical Management Solutions, W.R. Berkley Corporation, Boston, Massachusetts
| | - Paul M Werth
- Department of Orthopaedics, Dartmouth Health, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Patel S, Buller LT. Outpatient Hip and Knee Arthroplasty Can be Safe in Patients With Multiple Medical Comorbidities via Use of Evidence-Based Perioperative Protocols. HSS J 2024; 20:75-82. [PMID: 38356746 PMCID: PMC10863597 DOI: 10.1177/15563316231208431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Sohum Patel
- Department of Orthopedic Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Leonard T Buller
- Department of Orthopedic Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
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Fang C, Hagar A, Gordon M, Talmo CT, Mattingly DA, Smith EL. Differences in Hospital Costs among Octogenarians and Nonagenarians Following Primary Total Joint Arthroplasty. Geriatrics (Basel) 2021; 6:geriatrics6010026. [PMID: 33803233 PMCID: PMC8006031 DOI: 10.3390/geriatrics6010026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/26/2021] [Accepted: 03/07/2021] [Indexed: 11/16/2022] Open
Abstract
The proportion of patients over the age of 90 years continues to grow, and the anticipated demand for total joint arthroplasty (TJA) in this population is expected to rise concomitantly. As the country shifts to alternative reimbursement models, data regarding hospital expenses is needed for accurate risk-adjusted stratification. The aim of this study was to compare total in-hospital costs following primary TJA in octogenarians and nonagenarians, and to determine the primary drivers of cost. This was a retrospective analysis from a single institution in the U.S. We used time-drive activity-based costing (TDABC) to capture granular total hospital costs for each patient. 889 TJA’s were included in the study, with 841 octogenarians and 48 nonagenarians. Nonagenarians were more likely to undergo total hip arthroplasty (THA) (70.8% vs. 42.4%; p < 0.0001), had higher ASA classification (2.6 vs. 2.4; p = 0.049), and were more often privately insured (35.4% vs. 27.8%; p = 0.0001) as compared to octogenarians. Nonagenarians were more often discharged to skilled nursing facilities (56.2% vs. 37.5%; p = 0.0011), experienced longer operating room (OR) time (142 vs. 133; p = 0.0201) and length of stay (3.7 vs. 3.1; p = 0.0003), and had higher implant and total in-hospital costs (p < 0.0001 and 0.0001). Multivariate linear regression showed implant cost (0.700; p < 0.0001), length of stay (0.546; p < 0.0001), and OR time (0.288; p < 0.0001) to be the strongest associations with overall costs. Primary TJA for nonagenarians was more expensive than octogenarians. Targeting implant costs, length of stay, and OR time can reduce costs for nonagenarians in order to provide cost-effective value-based care.
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Affiliation(s)
- Christopher Fang
- New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA; (C.F.); (C.T.T.); (D.A.M.)
| | - Andrew Hagar
- Tufts Medical Center, Department of Orthopaedic Surgery, 800 Washington St, Boston, MA 02111, USA; (A.H.); (M.G.)
| | - Matthew Gordon
- Tufts Medical Center, Department of Orthopaedic Surgery, 800 Washington St, Boston, MA 02111, USA; (A.H.); (M.G.)
| | - Carl T. Talmo
- New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA; (C.F.); (C.T.T.); (D.A.M.)
| | - David A. Mattingly
- New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA; (C.F.); (C.T.T.); (D.A.M.)
| | - Eric L. Smith
- New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA; (C.F.); (C.T.T.); (D.A.M.)
- Correspondence:
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The influence of chronic kidney disease on the duration of hospitalisation and transfusion rate after elective hip and knee arthroplasty. Int Urol Nephrol 2018; 51:147-153. [DOI: 10.1007/s11255-018-2008-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022]
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Liao KM, Lu HY. Complications after total knee replacement in patients with chronic obstructive pulmonary disease: A nationwide case-control study. Medicine (Baltimore) 2016; 95:e4835. [PMID: 27631237 PMCID: PMC5402580 DOI: 10.1097/md.0000000000004835] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The incidence and prevalence of chronic obstructive pulmonary disease (COPD) is associated with increasing age. Osteoarthritis is also a growing problem in the aging population, and total knee replacement (TKR) is a common surgical procedure for this population. An increasing number of COPD patients are receiving TKR, but few studies have examined the complications and outcomes after TKR in COPD patients. The purpose of this study was to investigate the complications, including mortality, wound infections, hospitalization readmission, pneumonia (PN), and cerebrovascular accidents (CVAs) in patients with COPD after receiving TKR.The National Health Insurance operated by the government is a nationwide health care program with universal coverage in Taiwan. It covers approximately 99% of the total Taiwanese population of 23 million people. In this case-control study, we analyzed the longitudinally linked National Health Insurance Research Database, which consists of a cohort of 1,000,000 randomly selected enrollees retrospectively followed from 1996 to 2010. This study analyzed patients who underwent TKR surgery between January 1, 2004 and December 31, 2009 by identifying the International Classification of Diseases, Ninth Revision, Clinical Modification code. We separated patients into COPD and non-COPD groups. Five study outcomes and complications were measured after TKR, including mortality for 1 and 3 years, wound infections for 1 and 2 years, hospitalization readmission for 30 and 90 days, PN for 30 and 90 days, and CVAs.A total of 3431 patients who underwent TKR surgery were identified, including 358 patients with COPD and 3073 patients without COPD. The COPD group had a higher percentage of 90-day PN (3.7% vs. 1.1%), 30-day readmission (7.0% vs. 4.0%), 30-day CVA (1.7% vs. 0.6%), 90-day CVA (3.9% vs. 2.1%), and 3-year mortality (3.9% vs. 2.1%) than the non-COPD group. COPD was associated with 90-day PN (adjusted hazard ratio[HR)] = 2.12, P = 0.030) after adjusting for sex, cardiovascular disease, and CVA occurrence.Patients with COPD had a higher risk of PN after TKR than patients without COPD, but no significant differences were found for CVAs and mortality.
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Affiliation(s)
- Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yun-Lin, Taiwan
- Correspondence: Hsueh-Yi Lu, Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yun-Lin, 640 Taiwan (e-mail: )
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Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost. J Arthroplasty 2016; 31:54-8. [PMID: 27329578 DOI: 10.1016/j.arth.2016.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program. METHODS Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions. RESULTS Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%. CONCLUSION The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.
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Jämsen E, Nevalainen PI, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop 2015; 86:175-82. [PMID: 25409255 PMCID: PMC4404767 DOI: 10.3109/17453674.2014.987064] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 09/08/2014] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Perioperative hyperglycemia has been associated with adverse outcomes in several fields of surgery. In this observational study, we identified factors associated with an increased risk of hyperglycemia following hip and knee replacement. PATIENTS AND METHODS We prospectively monitored changes in glucose following primary hip and knee replacements in 191 patients with osteoarthritis. Possible associations of patient characteristics and operation-related factors with hyperglycemia (defined as glucose > 7.8 mmol/L in 2 consecutive measurements) and severe hyperglycemia (glucose > 10 mmol/L) were analyzed using binary logistic regression with adjustment for age, sex, operated joint, and anesthesiological risk score. RESULTS 76 patients (40%) developed hyperglycemia, and 48 of them (25% of the whole cohort) had severe hyperglycemia. Glycemic responses were similar following hip replacement and knee replacement. Previously diagnosed diabetes was associated with an increased risk of hyperglycemia and severe hyperglycemia, compared to patients with normal glucose metabolism, whereas newly diagnosed diabetes and milder glucose metabolism disorders had no effect. In patients without previously diagnosed diabetes, increased values of preoperative glycosylated hemoglobin (HbA1c) and fasting glucose on the day of operation were associated with hyperglycemia. Higher anesthesiological risk score-but none of the operation-related factors analyzed-was associated with an increased risk of hyperglycemia. INTERPRETATION Perioperative hyperglycemia is common in primary hip and knee replacements. Previously diagnosed diabetes is the strongest risk factor for hyperglycemia. In patients with no history of diabetes, preoperative HbA1c and fasting glucose on the day of operation can be used to stratify the risk of hyperglycemia.
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Affiliation(s)
- Esa Jämsen
- Coxa, Hospital for Joint Replacement, Tampere
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Rajamäki TJ, Jämsen E, Puolakka PA, Nevalainen PI, Moilanen T. Diabetes is associated with persistent pain after hip and knee replacement. Acta Orthop 2015; 86:586-93. [PMID: 25953426 PMCID: PMC4564781 DOI: 10.3109/17453674.2015.1044389] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/30/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity. PATIENTS AND METHODS The incidence of pain in the operated joint was surveyed 1-2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint. RESULTS 49 of the 134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2-38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2-15). INTERPRETATION Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1-2 years after primary hip or knee replacement.
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Affiliation(s)
| | - Esa Jämsen
- b 2 Coxa, Hospital for Joint Replacement
| | | | - Pasi I Nevalainen
- a 1School of Medicine, University of Tampere
- d 4 Department of Internal Medicine , Tampere University Hospital, Tampere, Finland
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Zeng Y, Shen B, Yang J, Zhou Z, Kang P, Pei F. Preoperative comorbidities as potential risk factors for venous thromboembolism after joint arthroplasty: a systematic review and meta-analysis of cohort and case-control studies. J Arthroplasty 2014; 29:2430-8. [PMID: 24996584 DOI: 10.1016/j.arth.2014.05.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/14/2014] [Accepted: 05/22/2014] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to examine the effect of preoperative comorbidities on the risk of VTE after joint arthroplasty surgery. Of 2235 citations identified for screening, 16 studies reporting 7,395,847 patients were eligible. The results showed that patients with cardiovascular disease, previous VTE history, neurologic disease and high anesthetic ASA rating had significantly higher VTE risk than those with no such preexisting medical comorbidities after joint arthroplasty. The presence of respiratory disease, urinary and kidney disease, coronary artery disease, endocrine disease, cancer and malignant disease, hematological disease and comorbidities index did not increase the risk of VTE in our study. The data suggest that risk assessment of patients may further reduce the overall incidence of DVT and PE from VTE prophylaxis.
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Affiliation(s)
- Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Yang
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Pengde Kang
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
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Romine LB, May RG, Taylor HD, Chimento GF. Accuracy and clinical utility of a peri-operative risk calculator for total knee arthroplasty. J Arthroplasty 2013; 28:445-8. [PMID: 23146586 DOI: 10.1016/j.arth.2012.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 07/09/2012] [Accepted: 08/13/2012] [Indexed: 02/01/2023] Open
Abstract
Utilizing the Medicare Provider Analysis and Review dataset, a, peri-operative total knee arthroplasty (TKA) risk calculator was created based on select preoperative comorbidities. We retrospectively identified and reviewed 2284 primary TKAs at a single institution from 2000-2008. A numerical, predicted complication risk was established for each patient. Actual complications occurring within the first 14 post-operative days were recorded. Statistical analysis was performed using the C-statistic and ANOVA test. Patients with higher predicted probability of a complication did show higher complication rates. The corresponding C-statistic was 0.609. (95% Confidence Interval: 0.542-0.677). When the patients were divided into 4 groups based on their calculated complication risk (0-5%, 5-10%, 10-25%, >25%) the statistical significance of the associated ANOVA was P < .001, showing that patients with higher predicted risk experienced more complications, and those with lower predicted risk experienced fewer complications. Based on our results, the calculator has predictive value and is clinically relevant.
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Petruccelli D, Rahman WA, de Beer J, Winemaker M. Clinical outcomes of primary total joint arthroplasty among nonagenarian patients. J Arthroplasty 2012; 27:1599-603. [PMID: 22552218 DOI: 10.1016/j.arth.2012.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/08/2012] [Indexed: 02/01/2023] Open
Abstract
A retrospective cohort study and a comparative literature review were undertaken to determine outcomes and survival/mortality rates among nonagenarian patients who underwent total joint arthroplasty (TJA). Thirty-nine patients who underwent TJA (14 hips, 25 knees) aged 90+ years were identified from a database of 9817 primary TJA cases performed at one hospital between 1998 and 2010. Findings were compared to synthesized data from relevant published literature review (LR). The mean age was 91.3 (±1.4) years, 79.5% were rated by the American Society of Anesthetists as 3+. Medical complication rate was 25.6% vs 36.2% for LR cases (P = .219). Perioperative death rate was 2.6% vs 2.1% among LR cases (P = 1.000). At 3.8-year follow-up, mortality rate was 59% (LR, 58.2%; 5.1 years), with a mean age of 95.2 (±3.5) years at death (LR, 96.3 ± 3.4). Excellent clinical outcomes were achieved. Primary TJA remains a viable and effective procedure in nonagenarian patients.
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Affiliation(s)
- Danielle Petruccelli
- Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada
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Mercuri LG. Avoiding and Managing Temporomandibular Joint Total Joint Replacement Surgical Site Infections. J Oral Maxillofac Surg 2012; 70:2280-9. [DOI: 10.1016/j.joms.2012.06.174] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 05/31/2012] [Accepted: 06/03/2012] [Indexed: 11/29/2022]
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Schwarzkopf R, Katz G, Walsh M, Lafferty PM, Slover JD. Medical clearance risk rating as a predictor of perioperative complications after total hip arthroplasty. J Arthroplasty 2011; 26:36-40. [PMID: 20452180 DOI: 10.1016/j.arth.2010.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 03/16/2010] [Indexed: 02/01/2023] Open
Abstract
Hip arthroplasty has become the standard treatment of end-stage osteoarthritis. However, postoperative complications are the risks associated with joint arthroplasty, which most significantly impact patient results and the total cost of care. Currently, no predictive system has been developed for categorizing levels of risk for the development of postoperative complications in patients undergoing total hip arthroplasty. We examined the association between the medical clearance risk rating by the physician performing the preoperative clearance examination and postoperative complications after total hip arthroplasty. We have demonstrated a significant association between the medical clearance risk rating and postoperative urinary track infection, and the American Society of Anesthesiologist score but no significant association to other complications. This study presents a predictive patient characteristic that may help us identify among our patients the ones that may benefit from a personally tailored preoperative planning and evaluation but demonstrates further work is necessary to better predict the risk of complications after total hip arthroplasty.
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Affiliation(s)
- Ran Schwarzkopf
- Division of Adult Reconstruction Surgery, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
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Berend KR, Morris MJ, Skeels MD, Lombardi AV, Adams JB. Perioperative complications of simultaneous versus staged unicompartmental knee arthroplasty. Clin Orthop Relat Res 2011; 469:168-73. [PMID: 20683688 PMCID: PMC3008868 DOI: 10.1007/s11999-010-1492-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The complication risk of staged versus simultaneous total knee arthroplasty continues to be debated in the literature. Previous reports suggest unicompartmental knee arthroplasty provides a more rapid functional recovery than total knee arthroplasty. However, little data exist on whether simultaneous unicompartmental knee arthroplasty can be performed without increasing the perioperative risk compared with staged unicompartmental knee arthroplasty. QUESTIONS/PURPOSES We therefore asked if there is an increased risk of perioperative complications with bilateral simultaneous unicompartmental knee arthroplasty. METHODS We retrospectively compared 141 patients (282 knees) treated with staged unicompartmental knee arthroplasty with 35 patients (70 knees) treated with simultaneous unicompartmental knee arthroplasty to evaluate perioperative complications and short-term results assessed by Knee Society function scores and the Lower Extremity Activity Scale. RESULTS Patients who underwent simultaneous unicompartmental knee arthroplasty had a shorter cumulative operative time (109 versus 122 minutes), a shorter cumulative length of hospital stay (1.7 versus 2.5 days), higher Knee Society function scores at most recent followup (88 versus 73), and higher Lower Extremity Activity Scale (12.0 versus 10.2) without a difference in perioperative complications. The simultaneous cohort was younger (59 versus 63 years of age) and less obese (body mass index 31 versus 33 kg/m(2)) than the staged group. CONCLUSIONS Although we found a substantial bias for performing simultaneous unicompartmental knee arthroplasty in younger and less obese patients, these data suggest it can be performed without increasing perioperative morbidity or mortality in this patient population. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Keith R Berend
- Joint Implant Surgeons, Inc, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA.
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Jämsen E, Furnes O, Engesaeter LB, Konttinen YT, Odgaard A, Stefánsdóttir A, Lidgren L. Prevention of deep infection in joint replacement surgery. Acta Orthop 2010; 81:660-6. [PMID: 21110700 PMCID: PMC3216074 DOI: 10.3109/17453674.2010.537805] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 10/04/2010] [Indexed: 01/31/2023] Open
Affiliation(s)
- Esa Jämsen
- Hospital for Joint Replacement, Tampere, Finland.
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Abstract
Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages <2 days.
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Affiliation(s)
- Adolph V Lombardi
- Joint Implant Surgeons, Inc, The Ohio State University, New Albany, Ohio, USA.
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Jämsen E, Nevalainen P, Kalliovalkama J, Moilanen T. Preoperative hyperglycemia predicts infected total knee replacement. Eur J Intern Med 2010; 21:196-201. [PMID: 20493422 DOI: 10.1016/j.ejim.2010.02.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 01/21/2010] [Accepted: 02/16/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND Diabetes increases the risk of surgical site infections. In many patients undergoing total knee replacement, however, diabetes has not been diagnosed. The purpose of this study was to analyze the applicability of preoperative screening for hyperglycemia in identifying patients predisposed to infected knee replacement. METHODS A recent series of 1565 primary total knee replacements performed due to osteoarthritis in a specialized, publicly funded hospital for joint replacement was reviewed. RESULTS Preoperative hyperglycemia was significantly associated with infected knee replacement: during the 1-year follow-up infection occurred in 0.44%, 0.93% and 2.42% of patients with preoperative plasma glucose <6.1 mmol/l (<110 mg/dl), 6.1-6.9 mmol/l (110-125 mg/dl) and > or =7.0 mmol/l (> or =126 mg/dl). In age- and gender-adjusted analysis the patients with the highest glucose levels had a 4-fold risk for infected knee replacement compared to the patients with the lowest glucose. Obesity increased the risk of infected knee replacement, but the effect of hyperglycemia on the infection rates remained significant also after adjustment for body mass index. None of the patients with normal but 2.8% of patients with increased glycosylated hemoglobin (>6.5%) experienced infected knee replacement. CONCLUSION Obesity and hyperglycemia associate with a higher risk of infected knee replacement. Preoperative screening of plasma glucose is an efficient way to identify patients in increased risk of infection following primary total knee replacement.
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Affiliation(s)
- Esa Jämsen
- Medical School, University of Tampere, FIN-33014, Finland.
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Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 2009; 24:84-8. [PMID: 19604665 DOI: 10.1016/j.arth.2009.05.016] [Citation(s) in RCA: 256] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 05/11/2009] [Indexed: 02/01/2023] Open
Abstract
The study aims to delineate the deep infection rates and infection risk factors for primary total knee and total hip arthroplasty patients. A retrospective review was conducted on 6108 patients from 1991 to 2004. The deep infection cases were compared to the noninfected cohort whereby infection risk factors were identified. Of the 8494 joint arthroplasties, 43 (0.51%) developed a deep infection (30 total knee arthroplasties, 13 total hip arthroplasties). Patients with a body mass index greater than 50 had an increased odds ratio of infection of 21.3 (P < .0001). Diabetic patients were 3 times as likely to become infected compared to nondiabetic patients (P = .0027). Simultaneous bilateral total joint arthroplasties were found to have developed infection 3 times less frequently than those performed as unilateral procedures (P = .0024). The average age in our infection cohort was 64.3 and 68.4 in the noninfected cohort. In this retrospective review study, obesity, diabetes, and younger age were found to be risk factors for joint arthroplasty infection.
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Affiliation(s)
- Robert A Malinzak
- The Center for Hip and Knee Surgery, St. Francis Hospital, Mooresville, Mooresville, Indiana, USA
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