Outcomes in smokers and alcohol users after fast-track hip and knee arthroplasty

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

[Knee flexion after hospitalisation is no predictor for functional outcome one year after total knee arthroplasty]

OBJECTIVE

In total knee arthroplasty (TKA), range of motion has become established as an important factor. The criterion of quality is set to flexion of 90° after hospitalisation. Currently, it is supposed to be a predictor for 1‑year postoperative outcome. However, as this correlation has not been proven, this clinical trial was performed.

METHODS

A total of 182 TKA recipients were analysed retrospectively. Outcomes were assessed before surgery, after hospitalization, 6 weeks and 1 year post surgery. They included knee range of motion (ROM) to answer the main hypothesis, but also KSS, SF-36, WOMAC, EQ-5D and VAS to evaluate knee function and quality of life. The patients were divided into two groups differing in achieving 90° flexion after hospitalisation and compared 6 weeks and 1 year after surgery.

RESULTS

Knee flexion differed significantly between groups from 91 to 70° in the group without the aim of 90° flexion after hospitalisation (E) (p < 0.001). After 6 weeks, flexion was improved to 112° ± 13° (E > 90°) vs. 106° ± 14° (E < 90°; p = 0.001). One year post surgery, knee flexion averaged 122° ± 10° (E > 90°) vs. 120° ± 10° (E < 90°) with no difference between the groups (p = 0.57) and no significant difference in all other scores concerning knee function and quality of life.

CONCLUSION

Flexion of 90° after hospitalisation is not adequate to predict medium-term outcomes after TKA. There is no advantage or disadvantage regarding whether the aim of 90° flexion is achieved.

Minor effect of patient education for alcohol cessation intervention on outcomes after acute fracture surgery: a randomized trial of 70 patients

BACKGROUND AND PURPOSE

High alcohol intake is associated with increased risk of postoperative complications. Alcohol cessation intervention is recommended prior to elective surgery. We investigated short- and long-term effects of perioperative intensive alcohol intervention in relation to acute ankle fracture surgery.

PATIENTS AND METHODS

70 patients requiring ankle fracture surgery and consuming ≥ 21 drinks weekly (1 drink = 12 g ethanol) were randomized to a manual-based 6-week intensive standardized alcohol cessation program, the Gold Standard Program (GSP-A), or treatment as usual (TAU), on the day of operation. GSP-A included 5 personal meetings, patient education, and motivational and pharmacological support (alcohol withdrawal prophylaxis, B vitamins, and low-dose disulfiram). Complications requiring treatment were measured after 6 weeks and 1 year. Alcohol intake was validated by biomarkers. Quality of life (QoL) was measured by the SF-36. Hospital costs were obtained from the National Hospital Costs Register.

RESULTS

Postoperatively, complete alcohol cessation was higher in the GSP-A than in the TAU group (18/35 vs. 5/35, number needed to treat = 3, p ≤ 0.001), but not lowrisk consumption in the long term (10/35 vs. 7/33, p = 0.5). Number of complications in the short and long term (12/35 vs. 14/33, 16/35 vs. 18/33), the SF-36 score, or hospital costs in the short and long term (€6,294 vs. €8,024, €10,662 vs. €12,198), were similar between the groups.

INTERPRETATION

Despite an effect on alcohol cessation and a positive tendency as regards the other outcomes, the postoperative complications, QoL, and costs were similar. Better perioperative strategies for acute surgical patients with high alcohol intake therefore need to be developed.

Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis

INTRODUCTION

Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA.

METHODS

We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users.

RESULTS

A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02).

DISCUSSION

Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.

Influence of day of surgery and prediction of LOS > 2 days after fast-track hip and knee replacement

Background and purpose - Enhanced recovery programs have reduced length of stay (LOS) after hip and knee arthroplasty (THA/TKA). Although risk factors disposing to prolonged LOS are well documented, there is limited information on the role of weekday of surgery. This study analyzed the role of weekday of surgery and other potential risk factors for LOS > 2 days.Patients and methods - We included 10,576 unselected consecutive procedures between January 2016 and August 2017 within a multicenter fast-track THA/TKA collaboration with prospective collection of preoperative characteristics. We used multiple regression analysis of potential risk factors for LOS > 2 days followed by construction of a simple risk score from 0 to 15 points based on the calculated odds ratios.Results - Mean LOS was 1.9 (SD 1.8) days, with 80% of patients having surgery from Monday to Wednesday. Of these, 17% (95% CI 16-18) had a LOS > 2 days vs. 19% (CI 17-21) in those operated on Thursday and Friday. Patients were scheduled evenly throughout the week regardless of risk of LOS > 2 days and despite the fact that 38% (CI 35-40) of patients with ≥ 6 points (16% of the total population) had a LOS > 2 days compared with 14% (CI 13-14) in those with < 6 points. In these "high-risk" patients, the fraction with LOS > 2 days increased when having surgery on Thursdays or Fridays (43% CI 38-49) compared with Monday to Wednesday (37% CI 34-39).Interpretation - A detailed preoperative risk assessment may be helpful to plan the weekday of surgery in order to decrease LOS and weekend hospitalization.

Patient-Related Risk Factors for Unplanned 30-Day Hospital Readmission Following Primary and Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Total knee arthroplasty (TKA) is a highly effective procedure for advanced osteoarthritis of the knee. Thirty-day hospital readmission is an adverse outcome related to complications, which can be mitigated by identifying associated risk factors. We aimed to identify patient-related characteristics associated with unplanned 30-day readmission following TKA, and to determine the effect size of the association between these risk factors and unplanned 30-day readmission. We searched MEDLINE and EMBASE from inception to 8 September 2020 for English language articles. Reference lists of included articles were searched for additional literature. Patients of interest were TKA recipients (primary and revision) compared for 30-day readmission to any institution, due to any cause, based on patient risk factors; case series were excluded. Two reviewers independently extracted data and carried out critical appraisal. In-hospital complications during the index admission were the strongest risk factors for 30-day readmission in both primary and revision TKA patients, suggesting discharge planning to include closer post-discharge monitoring to prevent avoidable readmission may be warranted. Further research could determine whether closer monitoring post-discharge would prevent unplanned but avoidable readmissions. Increased comorbidity burden correlated with increased risk, as did specific comorbidities. Body mass index was not strongly correlated with readmission risk. Demographic risk factors included low socioeconomic status, but the impact of age on readmission risk was less clear. These risk factors can also be included in predictive models for 30-day readmission in TKA patients to identify high-risk patients as part of risk reduction programs.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Quality of life outcomes in patients undergoing knee replacement surgery: longitudinal findings from the QPro-Gin study

Background

Many patients report postoperative pain, limited improvement in physical function and poor quality of life (QOL) after knee replacement surgery. Our study uses baseline predictors of change to investigate the QOL of patients with knee osteoarthritis 3-months after knee replacement surgery.

Methods

A prospective observational study was designed to evaluate patients (n = 132) scheduled for uni-compartmental or total knee replacement surgery who were assessed at baseline (preoperatively) and 3-months after. Physical and mental endpoints based on the component scores of the SF-12 and on the Western Ontario and McMaster Universities Arthritis (WOMAC) index were used to investigate patients’ QOL. Generalised estimating equation methodology was used to assess patients’ baseline characteristics (age, sex, education, body mass index (BMI), comorbidity, depressive symptoms, cognitive impairment, smoking/alcohol and type of surgery), the study endpoints and their changes over a 3-month post-surgery period. Stratified analyses by rehabilitation status after discharge were performed.

Results

Longitudinal data analysis showed that the baseline factors associated with improvement in general QOL at the 3-month post-surgery assessment were higher BMI, a high comorbidity, total (as opposed to unicompartmental) knee replacement and low education level. Data analysis of the patients who underwent rehabilitation after discharge revealed that the current smokers’ physical QOL worsened over time. The general QOL was unchanged over time in the presence of depressive symptomatology.

Conclusions

These findings underline the importance of using comprehensive assessment methods to identify factors affecting functionality and QOL, and developing interventions to improve the health/wellbeing of patients after knee replacement.

Investigation of the enhanced recovery after surgery protocol outcome on post colectomy patients

BACKGROUND

An enhanced recovery after surgery (ERAS) protocol was implemented to improve quality and cost effectiveness of surgical care in elective colorectal procedures.

METHODS

A retrospective study was conducted from July 2017 to June 2018. The ERAS protocol was initiated on 9 July 2018 and retrospectively reviewed in July 2019 by chart review, the American College of Surgeons National Surgical Quality Improvement Project database and risk stratification using Clavien-Dindo classification for all elective colorectal procedures.

RESULTS

A total of 109 patients, 55 (pre-ERAS) and 54 (post-ERAS) are included in the final analysis. There were no differences in complications were recorded (p = 0.37) and 30-day readmissions (p = 0.785). The mean hospital stay was 5.89 ± 2.62 days in pre-ERAS and 4.94 ± 2.27 days in post-ERAS group which was statistically significant (p = 0.047).

CONCLUSIONS

An ERAS protocol for colorectal surgery harmonised perioperative care and decreased length of stay.

The Effects of Bundled Payment Programs for Hip and Knee Arthroplasty on Patient-Reported Outcomes

BACKGROUND

Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes after hip and knee arthroplasty based on hospital participation in Medicare's bundled payment programs.

METHODS

We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively.

RESULTS

Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (-1.8 point relative difference at 6 months; 95% confidence interval -3.2 to -0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (-2.3 point relative difference at 6 months; 95% confidence interval -4.0 to -0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference.

CONCLUSIONS

Patients receiving care at hospitals participating in Medicare's bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.

[Total knee and hip arthroplasty within 2 days : The Danish Fast-Track Model]

BACKGROUND

Patients in Denmark undergoing total knee or hip replacement are routinely discharged within 2 days of surgery. A critical examination of traditional treatment methods, combined with focused research, has during the last 20 years increasingly optimized the treatment course in such a way that it has become possible to radically reduce the length of stay (LOS).

BASICS OF THE FAST-TRACK MODEL

The most important elements of this Fast-Track model are described. The patient motivation and transfer of partial responsibility to the patient through intensive information, optimized operation techniques, as well as modern multi-modal pain therapy with early mobilization are key issues. The relatively small and homogenous health care system of Denmark offers good research conditions and the possibility of a fast implementation of the latest results, as well as a lump-sum based re-imbursement system without minimum stay-both factors have been favorable for the development of the Fast-Track model.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Readmission Rates for One Versus Two-Midnight Length of Stay for Primary Total Knee Arthroplasty: Analysis of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Database

BACKGROUND

The length of stay (LOS) in the hospital for total knee arthroplasty (TKA) has been declining over recent decades. The purpose of this study was to determine if patients with an LOS for TKA that includes only 1 midnight have an increased odds of 90-day readmission compared with those with a 2-midnight LOS. We also sought to identify any predictors of 90-day hospital readmission among those readmitted during our period of analysis.

METHODS

A retrospective review of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was performed to identify patients with a 1-midnight or 2-midnight LOS for TKA during a 5-year period. The primary end point of this study was inpatient readmission within the 90-day postoperative period. A multiple logistic regression model and propensity score matching were used to compare the odds of 90-day readmission between 1-midnight and 2-midnight LOS. The secondary end points of this study were 90-day complications.

RESULTS

There were 96,250 TKA procedures identified in the database, and 46,709 met our inclusion criteria for LOS. No difference in 90-day-readmission odds between patients with a 1-midnight LOS and those with a 2-midnight LOS for primary TKA was identified. Male sex, single marital status, age of ≥80 years, type-I diabetes, previous smoking, narcotic use prior to surgery, and a higher American Society of Anesthesiologists (ASA) scores increased the odds of 90-day readmission. Patients in the age group of ≥50 to <65 years, those with a higher preoperative hemoglobin level, and those with a positive social history of alcohol use were found to have decreased odds of readmission.

CONCLUSIONS

We found no association between the LOS for primary TKA (1 midnight compared with 2 midnights) and the 90-day readmission risk.

LEVEL OF EVIDENCE

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

Predicting Inpatient Dissatisfaction Following Total Joint Arthroplasty: An Analysis of 3,593 Hospital Consumer Assessment of Healthcare Providers and Systems Survey Responses

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, created by the Centers for Medicare and Medicaid, is directly tied to hospital reimbursement. The purpose of this study is to identify factors that are predictive HCAHPS survey responses following primary hip and knee arthroplasty.

METHODS

Prospectively collected HCAHPS responses from patients undergoing elective hip and knee arthroplasty between January 2013 and October 2017 at our institution were analyzed. Patient age, gender, race, marital status, body mass index, American Society of Anesthesiologists score, preoperative pain score, smoking status, alcohol use, illegal drug use, socioeconomic quartile, insurance type, procedure type, hospital type (academic vs community), distance to medical center, length of stay (LOS), and discharge disposition were obtained and correlated with HCAHPS inpatient satisfaction scores.

RESULTS

Responses from 3593 patients were obtained: 1546 total hip arthroplasties, 1899 total knee arthroplasties, and 148 unicompartmental knee arthroplasties. Mean overall HCAHPS score was 79.2. Women had lower inpatient satisfaction than men (77.6 vs 81.6, P < .001). Alcohol consumers had lower inpatient satisfaction than abstainers (77.7 vs 81.6, P < .001). Inpatient satisfaction varied by socioeconomic quartile (P < .001) with patients in the highest quartile having lower satisfaction than patients in all other quartiles (P < .001). Patients discharged to a facility had lower inpatient satisfaction than those discharged home (71.2 vs 80.2, P < .001). An inverse correlation between inpatient satisfaction and LOS (r = -0.19, P < .001) and a direct correlation between satisfaction and distance to medical center (r = 0.06, P < .001) were seen.

CONCLUSION

Patients more likely to report lower levels of inpatient satisfaction after total joint arthroplasty are female, affluent, and alcohol consumers, who are discharged to postacute care facilities. Inpatient satisfaction was inversely correlated with LOS and positively correlated with distance from patient home to medical center. These findings provide targets for improvements in TJA inpatient care.

Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 1-Year Postdischarge Health Care Costs

Background:

In 2014, the Medical University of South Carolina (MUSC) implemented a Tobacco Dependence Treatment Service (TDTS) consistent with the Joint Commission (JC) standards recommending that hospitals screen patients for smoking, provide cessation support, and follow-up contact for relapse prevention within 1 month of discharge. We previously demonstrated that patients exposed to the MUSC TDTS were approximately half as likely to be smoking one month after discharge and 23% less likely to have a 30-day hospital readmission. This paper examines whether exposure to the TDTS influenced downstream health care charges 12 months after patients were discharged from the hospital.

Methods:

Data from MUSC’s electronic health records, the TDTS, and statewide health care utilization datasets (eg, hospitalization, emergency department, and ambulatory surgery visits) were linked to assess how exposure to the MUSC TDTS impacted health care charges. Total health care charges were compared for patients with and without TDTS exposure. To reduce potential TDTS exposure selection bias, propensity score weighting was used to balance baseline characteristics between groups. The cost of delivering the MUSC TDTS intervention was calculated, along with cost per smoker.

Results:

The overall adjusted mean health care charges for smokers exposed to the TDTS were $7299 lower than for those who did not receive TDTS services (P=0.047). The TDTS cost per smoker was modest by comparison at $34.21 per smoker eligible for the service.

Discussion:

Results suggest that implementation of a TDTS consistent with JC standards for smoking cessation can be affordably implemented and yield substantial health care savings that would benefit patients, hospitals, and insurers.

Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting

BACKGROUND

Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.

METHODS

In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.

RESULTS

After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).

CONCLUSION

In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 30-, 90-, and 180-Day Hospital Readmission Rates

INTRODUCTION

Smoking is a risk factor for hospitalization and interferes with patient care due to its effects on pulmonary function, wound healing, and interference with treatments and medications. Although benefits of stopping smoking are well-established, few hospitals provide tobacco dependence treatment services (TDTS) due to cost, lack of mandatory tobacco cessation standards and lack of evidence demonstrating clinical and financial benefits to hospitals and insurers for providing services.

METHODS

This study explored the effect of an inpatient TDTS on 30-, 90-, and 180-day hospital readmissions. To carry out this work, 3 secondary datasets were linked, which included clinical electronic health record data, tobacco cessation program data, and statewide health care utilization data. Odds ratios (ORs) were calculated using inverse propensity score-weighted logistic regression models, with program exposure as the primary independent variable and 30 (90 and 180)-day readmission rates as the dependent variable, and adjustment for putative covariates.

RESULTS

Odds of readmission were compared for patients who did and did not receive TDTS. At 30 days postdischarge, smokers exposed to the TDTS had a lower odds of readmission (OR=0.77, P=0.031). At 90 and 180 days, odds of readmission remained lower in the TDTS group (ORs=0.87 and 0.86, respectively), but were not statistically significant.

DISCUSSION

Findings from the current study, which are supported by prior studies, provide evidence that delivery of TDTS is a strategy that may help to reduce hospital readmissions.

The Effect of Smoking on Thirty-Day Postoperative Complications After Total Joint Arthroplasty: A Propensity Score-Matched Analysis

BACKGROUND

Total joint arthroplasty (TJA) is a highly successful treatment, but is burdensome to the national healthcare budget. National quality initiatives seek to reduce costly complications. Smoking's role in perioperative complication after TJA is less well known. This study aims to identify smoking's independent contribution to the risk of short-term complication after TJA.

METHODS

All patients undergoing primary TJA between 2011 and 2012 were selected from the American College of Surgeon's National Surgical Quality Improvement Program's database. Outcomes of interest included rates of readmission, reoperation, mortality, surgical complications, and medical complications. To eliminate confounders between smokers and nonsmokers, a propensity score was used to generate a 1:1 match between groups.

RESULTS

A total of 1251 smokers undergoing TJA met inclusion criteria. Smokers in the combined total hip and knee arthroplasty cohort had higher 30-day readmission (4.8% vs 3.2%, P = .041), were more likely to have a surgical complication (odds ratio 1.84, 95% confidence interval 1.21-2.80), and had a higher rate of deep surgical site infection (SSI) (1.1% vs 0.2%, P = .007). Analysis of total hip arthroplasty only revealed that smokers had higher rates of deep SSI (1.3% vs 0.2%, P = .038) and higher readmission rate (4.3% vs 2.2%, P = .034). Analysis of total knee arthroplasty only revealed greater surgical complications (2.8% vs 1.2%, P = .048) and superficial SSI (1.8% vs 0.2%, P = .002) in smokers.

CONCLUSION

Smoking in TJA is associated with higher rates of SSI, surgical complications, and readmission.

Smoking is associated with earlier time to revision of total knee arthroplasty

BACKGROUND

Smoking is associated with early postoperative complications, increased length of hospital stay, and an increased risk of revision after total knee arthroplasty (TKA). However, the effect of smoking on time to revision TKA is unknown.

METHODS

A total of 619 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to the patient smoking status. Smoking status was then analyzed for associations with time to revision TKA using a Chi square test. The association was also analyzed according to the indication for revision TKA.

RESULTS

Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to non-smokers (274/357, 77%, p=0.031). Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to ex-smokers (168/221, 76%, p=0.028). Subgroup analysis did not reveal a difference in indication for revision TKA (p>0.05).

CONCLUSIONS

Smokers are at increased risk of earlier revision TKA when compared to non-smokers and ex-smokers. The risk for ex-smokers was similar to that of non-smokers. Smoking appears to have an all-or-none effect on earlier revision TKA as patients who smoked more did not have higher risk of early revision TKA. These results highlight the need for clinicians to urge patients not to begin smoking and encourage smokers to quit smoking prior to primary TKA.

Impact of alcohol use on 30-day complication and readmission rates after elective spinal fusion (≥2 levels) for adult spine deformity: a single institutional study of 1,010 patients

BACKGROUND

Alcohol use has been shown to affect surgical outcomes. However, it is unknown what effect alcohol use has on postoperative complications or readmission rates in spinal fusion surgery. The aim of this study is to determine the impact of preoperative alcohol use on 30-day readmission rates or the complications profile after adult elective spinal fusion for deformity correction (≥2 levels).

METHODS

The medical records of 1,010 adult patients undergoing elective spinal fusion (≥2 levels) for spinal deformities at a major academic institution from 2005 to 2015 were reviewed. We identified 317 (31.4%) patients who had a history of alcohol prior to surgery and 693 (68.6%) patients who had no history of pre-operative alcohol consumption. The demographics, comorbidities, intra- and 30-day post-operative complication and readmission rates were collected for each patient. The primary outcome investigated in this study was the rate of 30-day readmissions and postoperative complication rates.

RESULTS

Baseline characteristics were similar between both cohorts. Intraoperative variables and the immediate postoperative complications profile were mostly similar between both cohorts. Overall, there was no significant difference between the 30-day readmission rates or complications profile between the two cohorts.

CONCLUSIONS

Our study suggests there is no significant difference in 30-day readmission or complication rates among adult patients with or without preoperative alcohol use undergoing elective correction of spinal deformities.

Fast track in hip arthroplasty

‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.

The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.

Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.

In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org

Alcohol consumption and the risk of postoperative mortality and morbidity after primary hip or knee arthroplasty - A register-based cohort study

Objective

To investigate the implications of low and moderate preoperative alcohol consumption on postoperative mortality and morbidity after primary hip and knee arthroplasty.

Methods

A total of 30,799 patients who underwent primary hip or knee arthroplasty between January 1^st, 2005 and October 8^th, 2011 with information on preoperative alcohol consumption (0 grams of pure alcohol/week, >0–168 g/week, >168–252 g/week, and >252 g/week) were identified through the Danish Anesthesia Database. The 90-day and 1-year risks of mortality (primary outcomes), 1-year risk of prosthetic infection, and 30-day risks of cardiovascular disease and deep venous thrombosis (secondary outcomes) were estimated by Cox regression analysis.

Results

We identified 285 (0.9%) deaths within the first 90 days and 694 (2.3%) within the first year. Within the first 30 days, 209 (0.7%) and 270 (0.9%) patients had acquired cardiovascular disease and deep venous thrombosis, respectively, and 514 (1.7%) patients developed prosthetic infection within the first year. The adjusted mortality models yielded hazard ratios of 0.55 (95% confidence interval [CI] 0.41 to 0.74) at 90 days and 0.61 (95% CI 0.51 to 0.73) at 1 year for the group consuming >0–168 g/week when compared to abstainers. Adjusted hazard ratios showed that the group consuming >0–168 g/week had a 0.91 (95% CI 0.75 to 1.11) risk of prosthetic infection, 0.68 (95% CI 0.50 to 0.92) risk of cardiovascular disease and 0.88 (95% CI 0.67 to 1.15) risk of deep venous thrombosis when compared to abstainers.

Conclusions

This study demonstrates that low-to-moderate alcohol consumption prior to primary hip or knee arthroplasty is associated with lower risks of mortality at both 90 days and 1 year after surgery and of cardiovascular disease after 30 days. More research from longitudinal studies is needed to identify specific causal relations and explanations.

Predictive value of B-type natriuretic peptide (BNP) for adverse cardiac events in patients undergoing primary total knee arthroplasty (TKA)

BACKGROUND

B-type natriuretic peptide (BNP) is a well-known biomarker to predict cardiac events following orthopedic procedures. However, further information regarding BNP can be completed. The present study aims to determine which of preoperative, postoperative or the difference between them (DVPPB) can best predict adverse cardiac events following TKA procedure and detect possible risk factors of high level of BNP.

METHODS

Between Jan. 2012 and Jan. 2014. 1120 included patients in 3 institutions have a minimum of 2-years follow-up. All clinical characteristics related to TKA procedure were put in total joint arthroplasty registry system and analyzed finally. The cut-off value of BNP predicting patients at increased risks of cardiac events after TKA was evaluated by the Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Our results reveal DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA, and the optimal cut-off value was 825.5 pg/ml with the highest Youden index of 0.62. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml.

CONCLUSIONS

DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml. We hope these results could be helpful to optimize health care among patients undergoing primary TKA.

Feasibility and Safety of 2-Day Discharge After Fast-Track Total Hip Arthroplasty: A Chinese Experience

BACKGROUND

A fast-track program (FT) can shorten hospital stay after total hip arthroplasty. The aim of this prospective randomized study was to investigate the feasibility and safety of 2-day discharge after fast-track total hip arthroplasty in a Chinese population.

METHODS

A total of 258 selected patients who underwent unilateral primary total hip arthroplasty were enrolled into the final cohort and were randomized into the FT (n = 126) and standard program group (n = 132). In the FT group, the patients received a multidisciplinary FT, whereas the patients in the standard program group only followed a standard care program. After setting restricted discharge criteria, we undertook follow-up evaluations to investigate the length of hospital stay, clinical performance, 30-day and 90-day complications, and 90-day admissions in both groups. A multivariate regression model was used to assess independent predictors of delayed discharge (>2 days).

RESULTS

The mean length of stay was reduced from 5.8 to 2.1 days after implementation of our FT (P < .001). Most patients in the FT group (82.5%) were discharged within 2 days postoperatively. However, the complications and readmissions appeared no difference between the two groups. The multivariate regression analysis identified age (P = .041), operative time (P < .001), intraoperative blood loss (P = .026), and total blood loss (P < .001) as the predictive factors for delayed discharge.

CONCLUSION

A 2-day discharge protocol after fast-track total hip arthroplasty can be safe and feasible in selected patients, without increasing the risk of complications and readmissions. Further efforts are needed to shorten operative time and reduce perioperative blood loss and eventually to shorten hospital stay.

Modifying Risk Factors for Total Joint Arthroplasty: Strategies That Work Nicotine

Smoking and nicotine use remain a major health care crisis in the United States. Although rates have dropped dramatically over the last 50 years, approximately 18% of the US adult population still smokes. The musculoskeletal effects of nicotine and other byproducts of smoking place patients at increased risk for perioperative complications including medical complication, wound healing problems, infection, and death. A comprehensive behavioral modification program with or without the use of nicotine replacement therapy has been shown to be most effective at smoking cessation around the time of planned surgery. Although literature suggests that smoking cessation 4-6 weeks before surgery can diminish risk, both current and former smokers are at increased risk for perioperative complications compared with those that have never smoked. Cotinine, a metabolite of nicotine, can be used to monitor smoking cessation before surgery.

Factors influencing length of hospital stay after primary total knee arthroplasty in a fast-track setting

PURPOSE

The goal of this study was to identify factors prior to surgery that are associated with an increased length of hospital stay after TKA using a fast-track protocol.

MATERIALS AND METHODS

In total, 879 consecutive patients who underwent primary TKA were included in this retrospective cohort study. A length of stay greater than or equal to three nights was considered an increased length of hospital stay. Univariable and multivariable generalized linear mixed models were used to identify potential factors associated with increased length of hospital stay.

RESULTS

Length of hospital stay was significantly associated with age [OR 1.01 (95 % CI 1.01-1.02); p < 0.001], gender [female vs. male, OR 1.07 (95 % CI 1.00-1.15); p = 0.04], ASA [ASA III/IV vs. ASA I, OR 1.22 (95 % CI 1.06-1.39); p = 0.005], living situation (alone vs. together, OR 1.08 (95 % CI 1.00-1.16); p = 0.04], neurological comorbidities [OR 1.14 (95 % CI 1.06-1.23); p < 0.001], musculoskeletal comorbidities [OR 0.91 (95 % CI 0.85-0.97); p = 0.005], anaesthesia [spinal vs. general, OR 0.86 (95 % CI 0.76-0.97); p = 0.02], and weekday of surgery [Thursday vs. Monday, OR 1.12 (95 % CI 1.02-1.23); p = 0.02].

CONCLUSIONS

Older age, female gender, ASA III/IV, people living alone, the presence of neurological comorbidities, general anaesthesia and surgery on Thursday were associated with an increased length of hospital stay. In clinical practice, the knowledge of factors associated with an increased length of hospital stay can be used to further optimize peri-operative protocols for patients at risk for an increased length of hospital stay after TKA.

LEVEL OF EVIDENCE

II.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty

BACKGROUND

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment.

METHODS

A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders.

RESULTS

Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD.

CONCLUSIONS

Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.

Smoking and alcohol behaviours in people following hip and knee arthroplasty: Data from the Osteoarthritis Initiative

BACKGROUND

Smoking and alcohol consumption has a negative effect on overall health. Limited evidence has been presented as to how these health behaviours may change between pre- and postoperative intervals in the initial 12 months post-arthroplasty. The purpose of this study was to address this uncertainty.

HYPOTHESIS

Smoking and alcohol consumption differs between pre- and post-THA/TKA and it differs between non-arthroplasty cohorts.

MATERIALS AND METHODS

Data from the Osteoarthritis Initiative (OAI), a population-based observational study in the USA, were gathered. In total, data from 287 people who had undergone THA or TKA from baseline to month 48 OAI follow-up assessments were analysed. Data on this cohort were compared to 287 age- and gender-matched people with osteoarthritis. Mean change from pre- to post-arthroplasty, and differences between arthroplasty and non-arthroplasty participants for smoking and alcohol consumption were assessed descriptively and through Wilcoxin-matched pairs test and Student t-tests (as appropriate).

RESULTS

The lifetime prevalence of smoking was high for people who received THA (99%) and TKA (96%). Prevalence of current smoking significantly decreased from 5 to 3% across the THA and TKA cohort in the initial 12 months post-arthroplasty (P<0.05). Similarly, there was a statistically significant decrease in weekly alcohol consumption post-arthroplasty for people who underwent THA and TKA (P<0.01), although the mean difference was only by 0.9 alcoholic drinks. The only statistically significant difference in smoking and alcohol consumption for arthroplasty to non-arthroplasty participants was in weekly alcohol consumption, which was higher by 0.3 drinks in the non-arthroplasty cohort (P=0.04).

CONCLUSIONS

Smoking and alcohol consumption decreased in the initial 12 months post-THA and TKA. This was not significantly different to an age- and gender-matched non-arthroplasty cohort. Whilst this is positive, a small group of patients still present with unhealthy lifestyle choices in relation to these behaviours post-arthroplasty.

LEVEL OF EVIDENCE

Level III - prospective case control study.

Preoperative prediction of potentially preventable morbidity after fast-track hip and knee arthroplasty: a detailed descriptive cohort study

OBJECTIVES

Construction of a simple preoperative risk score for patients in high risk of potentially preventable 'medical' complications. Secondary objectives were to construct simple preoperative risk scores for 'severe medical', 'surgical' and 'total' potentially preventable complications.

DESIGN

Prospective observational study.

SETTING

Elective primary unilateral total hip and knee arthroplasty with prospectively collected preoperative patient characteristics; similar standardised fast-track protocols; evaluation of complications through discharge and medical records; and complete 90 days follow-up through nationwide databases.

PARTICIPANTS

8373 consecutive unselected total hip arthroplasty (THA) and knee arthroplasty from January 2010 to November 2012.

RESULTS

There were 557 procedures (6.4%) followed by potentially preventable complications resulting in hospitalisation >4 days or readmission. Of 22 preoperative characteristics, 7 were associated with 379 (4.2%) potentially preventable 'medical' complications. Patients with ≥ 2 of the following, age ≥ 80 years, anticoagulant therapy, pulmonary disease, pharmacologically treated psychiatric disorder, anaemia and walking aids, composed 19.1% of the procedures; 55.7% constituted potentially preventable 'medical' complications that were mainly falls, mobilisation issues, pneumonias and cardiac arrhythmias. The number needed to be treated for a hypothetical intervention leading to 25% reduction in potentially preventable 'medical' complications was 34. THA, use of walking aids and cardiac disease were associated with 189 (2.2%) 'surgical' complications, but no clinically relevant preoperative prediction was possible.

CONCLUSIONS

Preoperative identification of patients at high risk of preventable 'medical', but not 'surgical', complications is statistically possible. However, clinical relevance is limited. Future risk indices should differ between 'medical' and 'surgical' complications, and also consider 'preventability' of these.

TRIAL REGISTRATION NUMBER

NCT01515670.

Social and Behavioral Factors in Total Knee and Hip Arthroplasty

Social and behavioral factors are important determinants of health outcomes in a number of medical conditions but their role in joint arthroplasty is poorly understood. In a cohort of 20,124 hip and knee arthroplasty procedures, smoking was associated with a significantly higher risk of surgical site infections (hazard ratio 1.7, 95% CI: 1.1-2.6), whereas alcohol use was associated with a lower risk of reoperations and revisions (hazard ratio 0.7, 95% CI: 0.5-0.8). There was no association between marital status and educational attainment with the risk of complications or reoperations in total hip and knee arthroplasty.

Tobacco Stained Fingers and Its Association with Death and Hospital Admission: A Retrospective Cohort Study

BACKGROUND

Among smokers, the presence of tobacco stains on fingers has recently been associated with a high prevalence of tobacco related conditions and alcohol abuse.

OBJECTIVE

we aimed to explore tobacco stains as a marker of death and hospital readmission.

METHOD

Seventy-three smokers presenting tobacco-tar staining on their fingers and 70 control smokers were followed during a median of 5.5 years in a retrospective cohort study. We used the Kaplan-Meier survival analysis and the log-rank test to compare mortality and hospital readmission rates among smokers with and smokers without tobacco stains. Multivariable Cox models were used to adjust for confounding factors: age, gender, pack-year unit smoked, cancer, harmful alcohol use and diabetes. The number of hospital admissions was compared through a negative binomial regression and adjusted for the follow-up time, diabetes, and alcohol use.

RESULTS

Forty-three patients with tobacco-stained fingers died compared to 26 control smokers (HR 1.6; 95%CI: 1.0 to 2.7; p 0.048). The association was not statistically significant after adjustment. Patients with tobacco-stained fingers needed a readmission earlier than smokers without stains (HR 2.1; 95%CI: 1.4 to 3.1; p<0.001), and more often (incidence rate ratio (IRR) 1.6; 95%CI: 1.1 to 2.1). Associations between stains and the first hospital readmission (HR 1.6; 95%CI: 1.0 to 2.5), and number of readmissions (IRR 1.5; 95%CI: 1.1 to 2.1) persisted after adjustment for confounding factors.

CONCLUSIONS

Compared to other smokers, those presenting tobacco-stained fingers have a high unadjusted mortality rate and need early and frequent hospital readmission even when controlling for confounders.

Low manipulation prevalence following fast-track total knee arthroplasty

BACKGROUND AND PURPOSE

Postoperative joint stiffness following total knee arthroplasty (TKA) may compromise the outcome and necessitate manipulation. Previous studies have not been in a fast-track setting with optimized pain treatment, early mobilization, and short length of stay (LOS), which may have influenced the prevalence of joint stiffness and subsequent manipulation. We investigated the prevalence of manipulation following fast-track TKA and identified patients at risk of needing manipulation.

PATIENTS AND METHODS

3,145 consecutive unselected elective primary unilateral TKA patients operated in 6 departments with well-defined fast-track settings were included in the study. Demographic data, prevalence, type and timing of manipulation, and preoperative and postoperative ROM were recorded prospectively, ensuring complete 1-year follow-up.

RESULTS

70 manipulations were performed within 1 year (2.2%) at a mean of 4 months after index surgery. Younger age and not using walking aids preoperatively were associated with a higher risk of manipulation. LOS ≤ 4 days (as opposed to a longer LOS) was not associated with an increased risk of manipulation.

INTERPRETATION

The prevalence of manipulation was lower or comparable to that in most published studies following more conventional pathways. Inherent patient demographics were identified as risk factors for manipulation whereas LOS ≤ 4 days was not. Thus, fast-track TKA does not result in increased risk of manipulation-despite a shorter LOS. Optimized pain treatment and early mobilization may contribute to these favorable results that support the use of fast-track.

Early morbidity after aseptic revision hip arthroplasty in Denmark

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

Risk of re-admission, reoperation, and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011

PURPOSE

To compare the risks of re-admission, reoperation, and mortality within 90 days of surgery in orthopedic departments with well-documented fast-track arthroplasty programs with those in all other orthopedic departments in Denmark from 2005 to 2011.

METHODS

We used the Danish hip and knee arthroplasty registers to identify patients with primary total hip arthroplasty or total knee arthroplasty. Information about re-admission, reoperation, and mortality within 90 days of surgery was obtained from administrative databases. The fast-track cohort consisted of 6 departments. The national comparison cohort consisted of all other orthopedic departments. Regression methods were used to calculate relative risk (RR) of adverse events, adjusting for age, sex, type of fixation, and comorbidity. Cohorts were divided into 3 time periods: 2005-2007, 2008-2009, and 2010-2011.

RESULTS

79,098 arthroplasties were included: 17,284 in the fast-track cohort and 61,814 in the national cohort. Median length of stay (LOS) was less for the fast-track cohort in all 3 time periods (4, 3, and 3 days as opposed to 6, 4, and 3 days). RR of re-admission due to infection was higher in the fast-track cohort in 2005-2007 (1.3, 95% CI: 1.1-1.6) than in the national cohort in the same time period. This was mainly due to urinary tract infections. RR of re-admission due to a thromboembolic event was lower in the fast-track cohort in 2010-2011 (0.7, CI: 0.6-0.9) than in the national cohort in the same time period. No differences were seen in the risk of reoperation and mortality between the 2 cohorts during any time period.

INTERPRETATION

The general reduction in LOS indicates that fast-track arthroplasty programs have been widely implemented in Denmark. At the same time, it appears that dedicated fast-track departments have been able to optimize the fast-track program further without any rise in re-admission, reoperation, and mortality rates.

Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study

OBJECTIVE

This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.

SETTING AND PARTICIPANTS

A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities.

OUTCOME MEASURES

The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality.

RESULTS

There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003).

CONCLUSIONS

Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.

Fast-track knee arthroplasty -- status and future challenges

BACKGROUND

Fast-track programs have been developed for different surgical procedures leading to higher patient satisfaction and lower morbidity. This concept has been extended to knee arthroplasty in recent years. The purpose of this narrative review was to discuss the different aspects of fast-track knee arthroplasty.

METHOD

Both authors searched the contemporary literature on minimally invasive knee arthroplasty and review articles on fast-track surgery aiming to summarize recent developments.

RESULTS

Length of stay after knee arthroplasty is influenced by preoperative risk factors, anaesthetic and surgical techniques, pain, orthostatic intolerance, cognitive function, sleep disturbances, bleeding and anaemia and finally muscle function and rehabilitation.

CONCLUSIONS

Fast-track surgery reduces the length of stay and the morbidity after knee arthroplasty.

CLINICAL RELEVANCE

Optimisation of pre-, per- and postoperative pathway for knee arthroplasty reduces morbidity after this type of surgery and results in shorter length of stay.