Obesity & hypertension are determinants of poor hemodynamic control during total joint arthroplasty: a retrospective review

An alternative method for personalized tourniquet pressure in total knee arthroplasty: a prospective randomized and controlled study

Tourniquet use always carries potential risks, which can range from mild transient functional impairments of thigh pain, skin blisters to severe permanent dysfunction of limb paralysis, nerve injuries or compartment syndrome. The ideal method for minimizing intraoperative tourniquet pressure (TP) for reducing postoperative complications remains controversial. In this prospective, randomized and controlled study, we reinvestigated an estimation formula for TP based on thigh circumferences and systolic blood pressure (SBP) with two traditional methods for TP determination in total knee arthroplasty (TKA): SBP plus 100 mmHg and a fixed value of 300 mmHg. TP values and postoperative thigh pain scores were compared among three groups. The intraoperative TP value of the formula-calculated group was lower than that of the traditional groups (14.7 mmHg, P = 0.3475 and 94.7 mmHg, P < 0.0001, respectively), while no differences of hemostatic effect at the surgical fields and wound complications were detected among groups. The thigh pain scores at the tourniquet site decreased gradually over time and the estimation group had the lowest scores at each timepoint after surgery. Estimation method for TP was easy and rapid, without relying on specific equipment. It could provide a practical low TP and comparable hemostatic effect in TKA using an inflating tourniquet.

"Uncontrolled" Hypertension Is Not an Independent Risk Factor for Adverse Short-Term Outcomes Following Total Joint Arthroplasty

BACKGROUND

Uncontrolled hypertension (HTN) is a risk factor for mortality following elective surgery and poor hemodynamic control during total joint arthroplasty (TJA). However, the relationship between uncontrolled HTN and TJA outcomes remains poorly understood. The purpose of this study is to better define HTN parameters that are predictive of adverse arthroplasty outcomes.

METHODS

This is a retrospective cohort analysis on patients who underwent primary TJA for osteoarthritis between 2017 and 2021 at a large orthopedic practice. Uncontrolled HTN was defined as a systolic blood pressure (SBP) > 140 mm Hg, or diastolic blood pressure (DBP) > 90 mm Hg. Spearman's rank correlations were used to evaluate relationships among uncontrolled HTN and operative duration, hemoglobin drop, allogenic transfusions, length of stay, intraoperative/postoperative complications, and readmissions.

RESULTS

Four thousand three hundred forty-five patients met the selection criteria, of which 55.1% (N = 2394) presented with uncontrolled HTN. In total, 17.1% (N = 745) and 3.2% (N = 138) of patients had an SBP ≥ 160 and 180 mm Hg, respectively. In addition, 1.9% of patients (N = 84) presented with SBP ≥ 200 mm Hg (N = 13) and/or DBP ≥ 100 mm Hg (N = 71). Eight-four percent (N = 626) of patients who presented with SBP > 160 mm Hg had been preoperatively prescribed HTN control medications. Receiver operator curve analysis demonstrated poor predictive value of blood pressure for all aforementioned outcome variables.

CONCLUSION

Our findings suggest that as defined, uncontrolled HTN is not an appropriate individual predictor of TJA outcomes and should not be used as a "hard stop" when determining eligibility for elective surgery. Further research utilizing a larger cohort is needed to define the relationship between HTN and TJA outcomes.

Is blood transfusion really required in simultaneous bilateral Total Knee Replacement: A retrospective observational study

Simultaneous bilateral TKA (SBTKA) in a single sitting is an attractive option for medically fit patients, with end-stage osteoarthritis (OA) of both the knees. It is a cost-effective procedure but is associated with increased blood loss and requirement for blood transfusion. We present a retrospective observational study of 144 patients who had SBTKA, with the mean age of 63.86 ± 7.38 years. We noted that all the cases of SBTKA would not require a blood transfusion, if the preoperative selection and optimization of the patient is done carefully and with the use of clean surgical technique and adequate thermocoagulation of the bleeders and perioperative use of tranexemic acid (TA) is done in these cases. 2/3rd of our patients did not require any blood transfusion, after SBTKA. We found that preexisting Hypertension and Hypothyroidism were associated with increased blood loss. The use of TA was a useful adjunctive measure to reduce perioperative blood loss. According to other studies which were reviewed there was no significant difference in blood loss with or without the use of a tourniquet. However, tourniquet was used in all patients in our study. The pre-operative level of Hemoglobin was an important factor to contribute to the requirement of blood transfusion after SBTKA. We recommend blood transfusion if the post-operative Hemoglobin level is less than 8.0 gm./dl.

Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives

BACKGROUND

The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider.

METHODS

Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors.

RESULTS

A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all).

CONCLUSION

This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.

Perioperative morbidity in total knee arthroplasty

Introduction

As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors.

Methods

It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications.

Results

Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation.

Conclusion

This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.

A Conceptual Model for the Evaluation of Surgical Missions

BACKGROUND

Medical missions to low and middle-income countries are increasingly frequent, with an estimated 6,000 trips sponsored by U.S. organizations accounting for approximately 200,000 surgical cases and $250 million in costs annually. However, these missions have received little critical evaluation. This paper describes the research program Operation Walk (Op-Walk) Boston, and proposes an evaluation model for similar surgical missions.

METHODS

We propose an evaluation model, borrowing from the work of Donabedian and enriched by evidence from our research program. The model calls for evaluation of the salient contextual factors (culture and beliefs), system management (structure, process, and outcomes), and sustainability of the program's interventions. We used these domains to present findings from the quantitative and qualitative research work of Op-Walk Boston.

RESULTS

Op-Walk's qualitative research findings demonstrated that cultural factors are important determinants of patients' perceptions of arthritis etiology, physical activity patterns, and treatment preferences. Quantitative assessments documented that Dominican patients had worse lower-extremity functional status (mean Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function score of 33.6) and pain preoperatively than patients undergoing total hip or knee replacement in the U.S. (WOMAC function score of 43.3 to 54), yet they achieved excellent outcomes (50-point improvement), comparable to those of their U.S. counterparts. Assessments of the quality and sustainability of the Op-Walk program showed that the quality of care provided by Op-Walk Boston meets Blue Cross Blue Shield Centers of Excellence (Blue Distinction) criteria, and that sustainable changes were transferred to the host hospital.

CONCLUSIONS

Our proposed model offers a method for formal assessment of medical missions that addresses the call for evidence of their merit. We suggest that surgical missions adopt quantitative and qualitative strategies to document their impact, identify areas of improvement, and justify program continuation, growth, and support.

First-ever stroke following hip replacement surgeries: a large population-based survey

OBJECTIVE

This study was designed to determine the prevalence, subtypes and risk factors of first-ever stroke following hip replacement (HR) in a large population of Taiwan.

METHODS

Using the National Health Insurance system of Taiwan, we identified patients undergoing HR from 2000 to 2011 and randomly selected 4 : 1 age- and sex-matched controls for each HR patients. The index date for HR patients was defined the date for HR. All study subjects were followed from the index date until stroke occurred at admission. T-test and chi-square test were used for continuous and categorical variables, respectively. The hazard ratios of risk factors were determined with Cox proportional hazard regression model.

RESULTS

A total of 3604 HR patients and 14 394 controls were enrolled. In comparison with controls, patients undergoing HR had a significantly higher incidence of comorbidities (i.e. atrial fibrillation, hypertension, diabetes) and consumed more medications (i.e. antihypertension, antidiabetes, nonsteroid anti-inflammatory drugs and anticoagulants) before surgery. The HR patients had a significant higher incidence of first-ever stroke, especially for those aged over 65. (Hazard ratio: 1·33, 95% confidence interval: 1·12-1·58) The significantly higher risk for first-ever stroke occurred within 3 months and ≥ 1 year after HR. The incidence rate of ischaemic stroke is about five times than that of haemorrhagic stroke.

CONCLUSION

Our study identifies multiple risk factors that cause cerebrovascular complications after HR, which is vital in creating treatment plans to prevent for said problems.

In-hospital mortality risk for total shoulder arthroplasty: A comprehensive review of the medicare database from 2005 to 2011

Introduction:

The in-hospital mortality rate after total shoulder arthroplasty (TSA) is unknown. The purpose of this study is to quantify the in-patient mortality rates and associated demographic risk factors for patients undergoing a TSA from 2005 to 2011 using a comprehensive Medicare registry database.

Materials and Methods:

We conducted a retrospective review of the Medicare database within the PearlDiver database. The PearlDiver database is a publicly available Health Insurance Portability and Accountability Act-compliant national database that captures 100% of the Medicare hospital data for TSA between 2005 and 2011. Using International Classification of Diseases, Ninth Revision codes for TSA we identified a dataset of patients undergoing TSA as well as a subset of those for whom there was a death discharge (i.e., in-patient death). Risk for this outcome was further quantified by age, gender and year. Linear regression was performed to identify risk factors for the primary outcome.

Results:

A total of 101,323 patients underwent 125,813 TSAs between 2005 and 2011. There were 113 in-patient mortalities during this period. Thus the incidence of death was 0.09%. Increasing age was a significant risk factor for mortality (P = 0.03). Gender and year of procedure were not significant risk factors for mortality.

Conclusion:

The incidence of in-patient mortality for Medicare patients undergoing TSA between 2005 and 2011 was <1 in 1000 surgeries. Increased age is a significant predictor of mortality.

Level 4:

Retrospective analysis