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Carrier R, Laverdiere J, Grace ZT, Wakefield D, Sanzari L, Grosso MJ. Pre-Assessment Surgical Screening Clinics Provide a Safe and Equitable Alternative to Primary Care Evaluation in Total Joint Arthroplasty. J Arthroplasty 2025:S0883-5403(25)00471-1. [PMID: 40339934 DOI: 10.1016/j.arth.2025.04.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Revised: 04/28/2025] [Accepted: 04/29/2025] [Indexed: 05/10/2025] Open
Abstract
BACKGROUND Preoperative medical clearance for total joint arthroplasty (TJA) is valuable for identifying factors that could mitigate complication risks. Traditionally, preoperative clearance is obtained through a primary care provider (PCP). Literature has shown that Pre-Assessment Surgical Screening (PASS) clinics may enhance operating room efficiency, decrease surgical cancellations, reduce hospital costs, and improve patient care quality. The goal of this study was to compare 90-day surgical complication and cancellation rates between patients who received preoperative evaluation through a PASS clinic versus a PCP. METHODS This retrospective study included patients who underwent primary total joint arthroplasty (TJA) from January 2017 through January 2024 at a single high-volume joint arthroplasty institute. There were 17,515 patients who met inclusion criteria; 52.3% (n = 9,164) were preoperatively evaluated by the PASS program and 47.7% (n = 8,351) by a PCP. Patient demographics, health characteristics, surgical cancellations, and 90-day complications were collected from patient charts. Outcomes were compared between patients who underwent PCP clearance versus PASS clearance utilizing univariate and logistic regression analyses. RESULTS On average, patients assessed by the PASS program were older (67 versus 66 years, P = 0.01), had a higher Charlson Comorbidity Index (CCI) (P = < 0.01), and higher American Society of Anesthesiologists (ASA) scores (P = < 0.01). Patients evaluated by a PCP were two times more likely to experience postoperative cardiac arrhythmia (odds ratio (OR): 1.96; 95% confidence interval (CI): 1.08 to 3.57; P = 0.03) and wound dehiscence (OR: 1.89; 95% CI: 1.04 to 3.45; P = 0.04). Patients evaluated by the PASS clinic were also 1.5 times more likely to experience periprosthetic joint infection (PJI) (OR: 1.56; 95% CI: 1.08 to 2.25; P = 0.2). There was no significant difference in readmissions, total 90-day complications, or cancellations between the groups. CONCLUSION Patients evaluated by the PASS clinic presented with more comorbidities than patients evaluated by a PCP. Despite these baseline differences, total complications, readmission, and cancellation rates did not significantly differ. Preoperative evaluation clinics can be a helpful resource for mitigating surgical cancellations, postoperative complications, and readmissions in high-risk patient groups.
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Affiliation(s)
- Robert Carrier
- Connecticut Joint Replacement Institute, 114 Woodland St, Hartford, CT, US, 06105.
| | - Jake Laverdiere
- Connecticut Joint Replacement Institute, 114 Woodland St, Hartford, CT, US, 06105; Frank H. Netter MD School of Medicine, 370 Bassett Rd, North Haven, CT, US 06473
| | - Zachary T Grace
- University of Connecticut Health Center, Department of Orthopedic Surgery, 263 Farmington Ave, Farmington, CT, US, 06030
| | - Dorothy Wakefield
- Connecticut Joint Replacement Institute, 114 Woodland St, Hartford, CT, US, 06105
| | - Laura Sanzari
- Connecticut Joint Replacement Institute, 114 Woodland St, Hartford, CT, US, 06105
| | - Matthew J Grosso
- Connecticut Joint Replacement Institute, 114 Woodland St, Hartford, CT, US, 06105
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Ho CN, Wang WT, Hung KC, Liu WC, Liao SW, Chen JY, Lan KM. Impact of general vs. regional anaesthesia on one-year clinical outcomes and healthcare utilisation after lower limb arthroplasty: a retrospective study. Anaesthesia 2025; 80:488-498. [PMID: 39668611 DOI: 10.1111/anae.16511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2024] [Indexed: 12/14/2024]
Abstract
INTRODUCTION General anaesthesia and regional anaesthesia are used for hip and knee arthroplasty but their impact on long-term outcomes remains unclear. This study aimed to compare one-year clinical outcomes and healthcare utilisation in patients receiving general or regional anaesthesia for hip or knee arthroplasty. METHODS Using data from the TriNetX Global Collaborative Network, we conducted a retrospective analysis of 247,142 patients aged 40-90 y who underwent hip or knee arthroplasty between 2010 and 2023. After propensity score matching, 12,558 patients were included in the general anaesthesia and regional anaesthesia cohorts. The primary outcome was one-year all-cause mortality. Secondary outcomes included one-year incidence of dementia; cerebral infarction; pneumonia; major depression; care provider dependency; and readmission rates. Subgroup analyses according to sex, age (40-70 y vs. > 70 y) and timeframe (2010-2016 vs. 2017-2023) were also performed. RESULTS There was no significant difference in one-year mortality (hazard ratio 1.12, 95%CI 0.89-1.41, p = 0.322). General anaesthesia was associated with a lower incidence of major depression (hazard ratio 0.82, 95%CI 0.70-0.97, p = 0.021) and care provider dependency (hazard ratio 0.47, 95%CI 0.38-0.58, p < 0.001), but higher readmission rates (hazard ratio 1.22, 95%CI 1.16-1.29, p < 0.001) than regional anaesthesia. Subgroup analysis revealed that patient characteristics including sex and age, as well as evolving peri-operative care practices over time, may influence the comparative outcomes of general and regional anaesthesia in patients undergoing elective hip or knee arthroplasty. DISCUSSION Although general anaesthesia and regional anaesthesia showed comparable one-year mortality, general anaesthesia was associated with lower risks of major depression and care provider dependency but higher readmission rates than regional anaesthesia. These findings suggest that the choice of anaesthesia may have important implications for long-term outcomes beyond mortality.
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Affiliation(s)
- Chun-Ning Ho
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Wei-Cheng Liu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- The Department of Occupational Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung City, Taiwan
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Center of General Education, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Jen-Yin Chen
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Mao Lan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
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Marín-Peña O, Poultsides LA, Yildiz F, Enayatollahi MA, Chillemi C, Costantini J, Cui Q, Memtsoudis S. Is There a Difference in Outcome of Total Joint Arthroplasty When Regional Versus General Anesthesia Are Used? J Arthroplasty 2025; 40:S16-S17. [PMID: 39437859 DOI: 10.1016/j.arth.2024.10.082] [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: 09/22/2024] [Revised: 10/11/2024] [Accepted: 10/14/2024] [Indexed: 10/25/2024] Open
Affiliation(s)
- Oliver Marín-Peña
- Hip-Knee Unit, Department of Orthopaedics, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lazaros A Poultsides
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Fatih Yildiz
- Ortopedi ve Travmatoloji AD, Bezmialem Vakıf Üniversitesi, İstanbul, Turkey
| | | | - Claudio Chillemi
- Department of Orthopaedic Surgery, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Julian Costantini
- Knee Unit, Servicio de Ortopedia y Traumatologia Carlos E. Ottolenghi, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Quanjun Cui
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Stavros Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, New York
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Valle C, Valle S, Baier C. [Anaesthesiological concepts in knee joint arthroplasty and implementation of fast-track concepts in everyday clinical practice]. ORTHOPADIE (HEIDELBERG, GERMANY) 2025; 54:78-82. [PMID: 39661176 DOI: 10.1007/s00132-024-04592-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/11/2024] [Indexed: 12/12/2024]
Affiliation(s)
- Christina Valle
- Medical Park Chiemsee, Bernau-Felden, Deutschland
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland
| | - Sandro Valle
- Klinik für Anästhesie und Intensivmedizin RoMed Klinik Prien am Chiemsee, Harrasser Str. 61-63, 83209, Prien am Chiemsee, Deutschland.
| | - Clemens Baier
- Orthopädie Regensburg MVZ, Im Gewerbepark C10, 93059, Regensburg, Deutschland
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Telang S, Heckmann ND, Olsen A, De A, Stambough JB. Spinal Anesthesia in Total Hip Arthroplasty is Associated With Improved Outcomes in the American Joint Replacement Registry Population. Arthroplast Today 2024; 30:101566. [PMID: 39539684 PMCID: PMC11558039 DOI: 10.1016/j.artd.2024.101566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/17/2024] [Accepted: 09/24/2024] [Indexed: 11/16/2024] Open
Abstract
Background Despite previous studies showing benefits of spinal anesthesia (SA) for patients undergoing elective total hip arthroplasty (THA), most THA procedures throughout the United States still utilize general anesthesia (GA). Using the American Joint Replacement Registry data, our study explored outcome difference for patients undergoing THA administered SA vs GA. Methods All available THAs were identified using American Joint Replacement Registry data from 2017 to 2020. THA patients were categorized into 2 cohorts by anesthesia type. Demographics, hospital characteristics, and comorbidities were documented for each patient. Outcomes included operative time, length of stay, 30- and 90-day readmission, and 90-day all-cause revision. Chi-square analysis was used to assess categorical variables while multivariable regression analyzed the association between anesthesia type and outcomes of interest. Results A total of 217,124 THAs were identified, including 119,425 (55.0%) patients who received GA and 97,699 (45.0%) patients who received SA. Multivariable regression showed that SA was associated with a decreased risk of hospital length of stay >3 days (adjusted odds ratio [aOR] 0.4, 95% confidence interval [CI]: 0.34-0.36, P < .0001) and a lower likelihood of prolonged operative time (aOR 0.8, 95% CI: 0.79-0.82, P < .0001). Additionally, patients who received SA had lower rates of 90-day readmission (aOR 0.7, 95% CI: 0.67-0.78, P < .0001) and a decreased risk of 90-day all-cause revision (aOR 0.5, 95% CI: 0.47-0.54, P < .0001). Conclusions Patients receiving SA during THA had shorter operative time, reduced length of stay, and decreased rates of readmission and revision compared to patients who received GA. These findings add to the growing body of literature supporting the benefits of SA over GA for THA patients.
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Affiliation(s)
- Sagar Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
| | | | - Adam Olsen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Ayushmita De
- American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Jeffrey B. Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Malige A, DeRogatis M, Michaud A, Usewick M, Ng-Pellegrino A. The evolution of anesthetic management for total knee arthroplasty (TKA) patients: A hospital network experience. J Orthop 2024; 58:10-15. [PMID: 39035450 PMCID: PMC11259785 DOI: 10.1016/j.jor.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 06/22/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction In the face of an ongoing opioid epidemic and an aging population, the utilization of a successful multimodal pain regimen in patients undergoing total knee arthroplasty (TKA) is vital. This study looks to explore the effect of different types of anesthesia in addition to a multimodal pain regimen on post-operative outcomes after undergoing TKA. Materials and methods From January 2016 to December 2022, 783 charts of patients undergoing an elective TKA were reviewed. Patients undergoing primary, isolated, and unilateral TKA procedures were included. Patients were grouped into three study arms: 1) general anesthesia (GA); 2) general anesthesia with a local anesthetic adductor canal block (GA + ACB); 3) spinal anesthesia with local anesthetic adductor canal block (SA + ACB). Patients who received other anesthesia types or received ACB utilizing liposomal bupivacaine were excluded. Results Of the 420 included patients, 63 patients received GA, 148 GA + ACB, and 209 SA + ACB. Patients in the SA + ACB group had a shorter LOS compared to both the GA + ACB and GA groups (p < 0.01. The SA + ACB group had the lowest daily average OME requirement (p < 0.01). Finally, patients in the SA + ACB group had the lowest average total cost of $11,683.91 (p < 0.01). Discussion Spinal anesthesia with adductor canal block is effective in decreasing opioid usage and improving postoperative outcomes after TKA. Surgeons and anesthesiologists should look to utilize this anesthetic option along with a multimodal regimen when deciding how to best manage postoperative pain after TKA procedures. Level of evidence Level III.
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Affiliation(s)
- Ajith Malige
- St. Luke's University Health Network, Department of Orthopaedic Surgery, Bethlehem, PA, 18015, USA
| | - Michael DeRogatis
- St. Luke's University Health Network, Department of Orthopaedic Surgery, Bethlehem, PA, 18015, USA
| | - Allincia Michaud
- St. Luke's University Health Network, Department of Research and Innovations, Bethlehem, PA, 18015, USA
| | - Michael Usewick
- Temple University/St. Luke's School of Medicine, Bethlehem Campus, Bethlehem, PA, 18015, USA
| | - Anna Ng-Pellegrino
- St. Luke's University Health Network, Department of Research and Innovations, Bethlehem, PA, 18015, USA
- St. Luke's University Health Network, Department of Anesthesiology, Bethlehem, PA, 18015, USA
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Valle C, Valle S, Baier C. [Perioperative management and fast track in knee arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:833-839. [PMID: 39373777 DOI: 10.1007/s00132-024-04569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/26/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Knee arthroplasty is an established surgical treatment for advanced osteoarthritis of the knee. In view of the rising number of surgical procedures, increasing costs in the healthcare system with a parallel increase in patient age and comorbidities, an evidence-based perioperative management is gaining importance. Fast Recovery concepts comprise a range of evidence-based strategies for optimizing the perioperative course. By reducing perioperative risks and optimizing pre-, peri- and postoperative processes, complications can be reduced, as well as perioperative morbidity, while comprising faster convalescence. MATERIAL AND METHODS This review is based on a systematic literature search in the PubMed, Cochrane Library and Web of Science databases on the topic of perioperative optimization and evidence for Fast Recovery programs in knee resurfacing. RESULTS In knee arthroplasty, Fast Recovery protocols lead to a significant reduction in the length of stay in hospital without an increase in complication rates. Patients also benefit from a faster return to mobility and a reduced level of postoperative pain. The involvement of multidisciplinary teams, the optimization of pain therapy, the minimization of blood loss and early mobilization are key elements of these protocols. The implementation of Fast Recovery protocols in the perioperative care of patients is an effective strategy to improve surgical outcomes. Essential for the success of such programs is individualized multidisciplinary patient care with preoperative risk assessment, optimized pain management and early physiotherapeutic mobilization. Future research should focus on the long-term effects of these approaches and their adaptation to different patient populations.
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Affiliation(s)
- Christina Valle
- Medical Park Chiemsee, Birkenallee 41, 83233, Bernau am Chiemsee, Deutschland.
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Sandro Valle
- RoMed Klinik Prien am Chiemsee, Harrasser Str. 61-63, 83209, Prien am Chiemsee, Deutschland.
| | - Clemens Baier
- Orthopädie Regensburg MVZ, Im Gewerbepark C10, 93059, Regensburg, Deutschland.
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Lee HJ, Xu S, Liu EX, Lim JBT, Liow MHL, Pang HN, Tay DKJ, Yeo SJ, Chen JY. Successful 24-hour discharge for total knee arthroplasty: importance of timing of surgery and physiotherapy in enhanced recovery after surgery protocol. Singapore Med J 2024:00077293-990000000-00161. [PMID: 39434384 DOI: 10.4103/singaporemedj.smj-2023-280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/11/2024] [Indexed: 10/23/2024]
Abstract
INTRODUCTION The current literature is mixed on which patient factors, if any, predict the rate of successful discharge within 24 h of enhanced recovery after surgery (ERAS) total knee arthroplasty (TKA). This study aimed to investigate the influence of timing of surgery and physiotherapy on the rate of successful 24-h discharge. METHODS All 342 patients who underwent ERAS day surgery TKA from August 2020 to July 2021 were followed up prospectively. Patient characteristics and postoperative outcomes, such as number of physiotherapy sessions required before clearance for home, time taken after surgery to ambulate >10 m and length of stay (LOS), were recorded. Patients were grouped based on surgical end time (morning/afternoon/ evening) and time of physiotherapy review (morning/afternoon/evening/morning after). Patients successfully passed ERAS day surgery protocol if they were discharged within 24 h. RESULTS With regard to the timing of operation, the morning group had the shortest LOS (P = 0.001) and a higher ERAS day surgery pass rate than the afternoon group (P = 0.016). With regard to the timing of physiotherapy, the afternoon group took the shortest time to ambulate >10 m (P < 0.001), had the shortest LOS (P < 0.001) and had a higher ERAS day surgery pass rate as compared to the morning after the operation group (P = 0.005). CONCLUSION Patients who ended their operations in the morning and received physiotherapy review in the same afternoon were the most likely to be discharged within 24 h due to early ambulation and adequate time for spinal anaesthesia to wear off.
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Affiliation(s)
- Hong Jing Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Sheng Xu
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Eric Xuan Liu
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | | | - Hee Nee Pang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Buchanan MW, Gibbs B, Ronald AA, Novikov D, Yang A, Salavati S, Abdeen A. Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital? Clin Orthop Relat Res 2024; 482:1442-1451. [PMID: 38564795 PMCID: PMC11272343 DOI: 10.1097/corr.0000000000003054] [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] [Received: 10/06/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. QUESTIONS/PURPOSES When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? METHODS An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. RESULTS After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). CONCLUSION Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Brian Gibbs
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Andrew A. Ronald
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - David Novikov
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Allen Yang
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Seroos Salavati
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Ayesha Abdeen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
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Calkins TE, Johnson EP, Eason RR, Mihalko WM, Ford MC. Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study. J Arthroplasty 2024; 39:1463-1467. [PMID: 38103803 DOI: 10.1016/j.arth.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). METHODS We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). RESULTS All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). CONCLUSIONS Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. LEVEL OF EVIDENCE Level 3, Retrospective Cohort Comparison.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Evan P Johnson
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Robert R Eason
- University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marcus C Ford
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
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