Spinal anesthesia: should everyone receive a urinary catheter?: a randomized, prospective study of patients undergoing total hip arthroplasty

Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05.

RESULTS

Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis.

CONCLUSIONS

The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR.

LEVEL OF EVIDENCE

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

Routine Indwelling Urinary Catheterization Is Not Necessary During Total Hip Arthroplasty Performed Under Spinal Anesthesia

Background

Perioperative indwelling urinary catheterization remains common in patients undergoing total hip arthroplasty. This study sought to examine the effect of routine catheterization following total hip arthroplasty performed under spinal anesthesia on urinary complications.

Methods

A total of 991 consecutive patients who underwent primary total hip arthroplasty under spinal anesthesia over a 4-year period were retrospectively reviewed. Major postoperative urinary retention (POUR) was defined as persistent retention following 2 straight catheterizations, which required postoperative indwelling catheter placement. Minor POUR was defined as retention that resolved following 1 or 2 straight catheterizations. Statistical analyses were used to compare outcomes between those who received a routine indwelling catheter and those who did not.

Results

Of the 991 patients included, 498 (50.3%) underwent routine indwelling urinary catheter placement preoperatively. Routine indwelling catheterization was associated with a higher rate of urinary tract infection (1.4% vs 0.0%, P = .015), but a lower rate of minor POUR (5.0% vs 10.3%, P = .001). There was no difference with respect to the rate of major POUR or discharge with an indwelling catheter. Multivariate analyses demonstrated indwelling catheterization to be independently associated with a lower rate of minor POUR (P = .021), but there was no association with overall POUR, major POUR, or discharge with a urinary catheter.

Conclusion

These data suggest that routine indwelling urinary catheterization is likely unnecessary for patients undergoing total hip arthroplasty in the setting of spinal anesthetic and may even lead to increased risk of complications such as urinary tract infection.

Urinary catheter use in patients with hip fracture: Are current guidelines appropriate? A retrospective review

Background:

Guidelines for urinary catheterization in patients with hip fracture recommend limiting catheter use and using intermittent catheterization preferentially to avoid complications such as urinary tract infection (UTI) and postoperative urinary retention (POUR). We aimed to compare current practices to clinical guidelines, describe the incidence of POUR and UTI, and determine factors that increase the risk of these complications.

Methods:

We retrospectively reviewed the charts of patients with hip fracture who presented to a single large tertiary care centre in southeastern Ontario between November 2015 and October 2017. Data collected included comorbidities, catheter use and length of stay. We compared catheter use to guidelines, and investigated the incidence of and risk factors for POUR and UTI.

Results:

We reviewed the charts of 583 patients, of whom 450 (77.2%) were treated with a catheter, primarily indwelling (416 [92.4%]). Postoperative urinary retention developed in 98 patients (16.8%); however, it did not affect length of stay (p = 0.2). Patients with indwelling catheters for more than 24 hours after surgery had a higher incidence of POUR than those who had their catheter removed before 24 hours (65/330 [19.7%] v. 10/98 [10.2%]) (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.06–4.38). A UTI developed postoperatively in 62 patients (10.6%). Catheter use was associated with a 6.6-fold increased risk of UTI (OR 6.6, 95% CI 2.03–21.4). Patients with indwelling catheters did not have a significantly higher incidence of UTI than those with intermittent catheterization (57/416 [13.7%] v. 2/34 [5.9%]) (p = 0.2). Patients who developed a UTI had significantly longer catheter use than patients who did not (p < 0.002).

Conclusion:

Indwelling catheters were used frequently, which suggests low compliance with clinical guidelines. Longer duration of catheter use led to higher rates of UTI and POUR. Further investigation of the reasons for the common use of indwelling rather than intermittent catheterization is needed.

Risk Factors for Prolonged Time to Discharge in Total Hip Patients Performed in an Ambulatory Surgery Center due to Complaints of the Inability to Void

BACKGROUND

Postoperative urinary retention (POUR) is among the reasons for delay in discharge after outpatient total hip arthroplasty (THA), occurring in 2%-46% of patients. We hypothesized that the frequency of POUR following outpatient THA in the ambulatory surgery center (ASC) is low compared to previously reported rates and that management can be effective in the perioperative period when it is encountered.

METHODS

Three hundred seventy-seven THA patients (409 hips) who had arthroplasties in the ASC over a 5-year period were identified. Preoperatively, appropriate demographic information and medical comorbidities were collected from patient health history questionnaires completed during clinic visits. Intraoperatively, albumin volume administered and estimated blood loss were recorded. Postoperatively, post-anesthesia care unit medications, patients who reported an inability to urinate, and those who required urinary catheterization were recorded.

RESULTS

POUR occurred in only 2 patients but complaints of the inability to void occurred in 38 others for an incidence of 9.8%. Factors associated with POUR and the inability to urinate included older age, time spent in the ASC, and intraoperatively albumin volume administered. No significant differences were found in body mass index, preoperative hematocrit, estimated blood loss, surgical time, or operating time.

CONCLUSION

POUR was infrequent but the reported inability to urinate was not (9.8%) and can be safely managed when it does occur and we found that increased age and albumin volume over 500 mL may increase the risk for a prolonged length of stay due to the inability to urinate.

Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes.

METHODS

This retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, "any complication," and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

RESULTS

In 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of "any complication" (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of "any complication" (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes.

CONCLUSION

Despite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized.

LEVEL OF EVIDENCE

III.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors.

METHODS

Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis.

RESULTS

Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors.

CONCLUSION

A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this meta-analysis was to assess whether a urinary catheter is necessary for all patients in primary total knee arthroplasty (TKA).

METHODS

PubMed, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure were systematically searched for randomized controlled trials (RCTs). All RCTs were compared with receive either an indwelling urinary catheter or no urinary catheter in TKA. Primary outcomes were urinary retention and urinary tract infection. Secondary outcomes were the length of stay, duration of the surgery, and the first urination time.

RESULTS

A total of 6 RCTs involving 1334 patients were included in the meta-analysis. No significant difference between the 2 groups was found in urinary retention (P = .52), length of stay (P = .38), duration of the surgery (P = .55). However, patients with an indwelling catheter were associated with a higher risk of urinary tract infections and longer time for the first urination than patients without indwelling catheters (P = .009 and P = .004).

CONCLUSION

The available evidence indicates that patients without using the indwelling catheters could reduce urinary tract infections and the time for the first urination, without increase in the incidence of urinary retention in primary TKA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Does Symptomatic Benign Prostatic Hyperplasia Increase the Risk of Periprosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND

Periprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Using the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.

RESULTS

At two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.

CONCLUSION

In primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.

Indwelling urinary catheterization was unnecessary in non-drainage total knee arthroplasty: a randomized controlled trial

PURPOSE

To investigate whether catheterization remains necessary in non-drainage total knee arthroplasty (TKA) using combined spinal epidural anesthesia (CSEA) with a short-acting opioid by comparing (1) incidences of postoperative urinary retention (POUR), and (2) postoperative clinical outcomes between retained urinary catheter (UC) and non-retained urinary catheter (non-UC) groups.

METHODS

A total of 230 patients underwent non-drainage TKA using CSEA with fentanyl were randomized into UC and non-UC groups (115 patients each, 115 knees each). Incidences of POUR, clinical outcomes (intraoperative intravenous fluid, operative time, whole blood loss, urinary tract infection (UTI), and length of stay) were evaluated after the operation, while range of motion (ROM) and Knee society score (KSS) were evaluated 3- and 6-month postoperatively.

RESULTS

Incidences of POUR and other perioperative and postoperative clinical outcomes between the two groups were not significantly different. ROM and KSS at 3- and 6-month postoperatively revealed no significant differences between the groups.

CONCLUSION

Given no significant difference in POUR incidence, clinical outcomes and knee scores and functions, catheterization in non-drainage TKA under CSEA with a short-acting opioid might not be necessary.

CLINICAL TRIALS

Clinical Trials gov (NCT03341819) (11/09/2017).

Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial

Background

Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization.

Methods

Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined.

Results

Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively.

Conclusion

Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury.

Trial registration

Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07.

Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient’s Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497. Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review

PURPOSE

Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management.

METHODS

We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed.

RESULTS

The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h.

CONCLUSIONS

This review provided an up-to-date guide for the detection and management of POUR.

LEVEL OF EVIDENCE

Level III.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery

Postoperative urinary retention (POUR) may result from orthopaedic procedures and potentially lead to bacteremia and chronic voiding difficulties. Risk factors for POUR include age, undergoing joint arthroplasty, male sex, intraoperative intravenous fluid administration, operative time, and history of benign prostatic hyperplasia. Indwelling catheterization is the preferred management strategy for patients at risk for developing POUR. A consistent definition of POUR is needed in order to draw conclusions from future studies.

Prevalence and Factors Associated with Atrial Fibrillation Among Patients with Rheumatic Heart Disease

Introduction

Rheumatic heart disease (RHD) is one of the common causes of atrial fibrillation (AF) is associated with significant morbidity and mortality. There is a lack of data on the prevalence of AF and factors associated with increased risk of AF in patients with RHD from Nepal.

Methods

A total of 120 patients who received care at Nobel Medical College Teaching Hospital from January 2018 to February 2019 with a diagnosis of RHD with AF were enrolled. Demographic information, relevant clinical and laboratory parameters and predisposing conditions for AF were obtained from a structured questionnaire designed.

Results

The prevalence of AF was 120 (36.3%) out of 330 cases of RHD screened. The male to female ratio was 32:88. The mean age was 50.2 (range 22-80) years. Prevalence was slightly more in females (36.9%) as compared to males (34.7 %). The prevalence of AF in patients with predominant mitral stenosis (MS) was 66.6% and less in patients with predominant mitral regurgitation (MR) (16.6%). The prevalence of AF in cases of MS with mitral valve area (MVA) < 1.5 cm2 was 76.2% as compared to 23.7% in cases with MVA > 1.5 cm2. Mitral valve (MV) was the most commonly affected valve (83.3%) followed by the aortic valve (10%). Both mitral and aortic valves were involved in 6.6% of patients. Majority of patients (97.5%) had enlarged left atrium (>40mm), reduced estimated glomerular filtration rate (eGFR) of <90 ml/min (85.8%). Patients of RHD with AF were complicated with decreased left ventricular (LV) systolic function (67.5%), pulmonary artery hypertension (52.5%), left atrial clot (9.1%), stroke (8.3%), and peripheral embolism (2.5%).

Conclusions

AF is a common rhythm disorder in patients with RHD. Prevalence of AF is common in females, increases with age, increasing LA size, increased severity of MS and decreased level of eGFR.

[Risk factors for postoperative indwelling catheter following enhanced recovery after total knee arthroplasty]

Objective

To evaluate the risk factors for postoperative indwelling catheter following enhanced recovery after primary unilateral total knee arthroplasty (TKA) under general anesthesia.

Methods

Patients who underwent primary unilateral TKA under general anesthesia between January 2017 and August 2018 were enrolled in the study. Among them, 205 patients who met the selection criteria were included in the study, and the clinical data were collected, including gender, age, body mass index, preoperative range of motion, Hospital for Special Surgery (HSS) score, American Society of Anesthesiologists (ASA) score, disease type, comorbidity, hemoglobin, hematocrit, blood volume, length of operation and operation time, whether to keep drainage after surgery, intraoperative blood loss, total blood loss, and preoperative, intraoperative, postoperative fluid infusions, and total fluid infusion on the day of surgery, urine volume on the day of surgery. Univariate analysis and logistic regression analysis were used to screen the risk factors for postoperative indwelling catheter. Length of stay and incidences of complications (intermuscular vein thrombosis, deep vein thrombosis, pulmonary embolism, incision swelling and exudation, electrolyte disorder, nausea and vomiting, and urinary tract infection) were compared between the patients with or without indwelling catheter.

Results

Indwelling catheter occurred in 41 (20%) of 205 patients. Single factor analysis showed that the influence factors were age, gender, keeping drainage after surgery, total fluid infusion and urine volume on the day of surgery ( P<0.05). The multiple factors analysis showed that the males and more urine volume on the day of surgery were the significant risk factors for indwelling catheter after primary TKA ( P<0.05). In addition, postoperative length of stay was shorter and the incidence of urinary tract infection was lower in non-indwelling catheter group than in indwelling catheter group, showing significant differences ( P<0.05).

Conclusion

The male patients with more urine on the day of surgery have higher risk for indwelling catheter after primary unilateral TKA under general anesthesia with an enhanced recovery program.

Avoiding Urinary Catheterization in Patients Undergoing Atrial Fibrillation Catheter Ablation

Purpose

Indwelling urinary catheters are commonly inserted when administering general anesthesia. However, there are significant risks to routine IUC insertion. We compared urinary and other outcomes in a population of patients undergoing atrial fibrillation (AF) ablation with or without IUC.

Methods

This was a single center, retrospective review of patients undergoing AF ablation. Patients were identified by procedure codes and patient health characteristics and outcome data were manually extracted from electronic health records. The primary composite endpoint was 7-day periprocedural urinary outcomes including cystitis, dysuria, hematuria, urethral damage, or urinary retention.

Results

404 patients were included in the study, 297 with IUC and 107 without IUC. Uncatheterized patients were less likely to have congestive heart failure (CHF) (31.8% vs 43.4%; P = 0.039) and had a shorter procedure length (4.2 vs 4.9 hours; P < 0.001) with less fluid administered (1485 vs 2040 mL; P < 0.001). No urinary complications occurred in the uncatheterized group versus 14 in the catheterized group (P = 0.026). 3 patients in the uncatheterized group developed serious infections versus none in the catheterized group (P = 0.018). There was no incidence of death and no statistically significant difference in readmission in the 30 days after procedure.

Conclusions

There were no urinary complications in 107 patients who received no IUC during AF ablation. Avoiding bladder catheters during AF ablation procedures may lower incidence of adverse urinary complications without adding substantial risk of urinary retention.

Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia

BACKGROUND

The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia.

METHODS

Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups.

RESULTS

Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days.

CONCLUSION

Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia.

LEVEL OF EVIDENCE

Level II, retrospective comparative study.

The AAHKS Clinical Research Award: Prophylactic Tamsulosin Does Not Reduce the Risk of Urinary Retention Following Lower Extremity Arthroplasty: A Double-Blinded Randomized Controlled Trial

BACKGROUND

Postoperative urinary retention (POUR) is common. Selective alpha-1 adrenergic antagonists, such as tamsulosin, are effective for treating urinary retention. The purpose of this study is to determine whether perioperative prophylactic tamsulosin reduces the incidence of POUR following total hip and knee arthroplasty.

METHODS

Male patients 35 years of age and older undergoing primary total hip or knee arthroplasty at a single center from 2015 to 2018 were eligible for inclusion. Patients were randomized to receive tamsulosin 0.4 mg or placebo daily for 5 days preoperatively, the morning of surgery, and the first postoperative day. The incidence of POUR was determined during the postoperative hospitalization.

RESULTS

A total of 176 patients were enrolled in the study. Two patients were withdrawn prior to randomization. The remaining 174 were randomized to tamsulosin (n = 87) or placebo (n = 87). After an additional 43 patients were withdrawn prior to surgery, 131 patients completed the study (tamsulosin, n = 64; placebo, n = 67). A total of 42 patients (32.1%) developed POUR, with 18 cases (28.1%) in the tamsulosin group and 24 cases (35.8%) in the placebo group (P = .345), resulting in an odds ratio of 0.701 and a risk difference of 7.69%.

CONCLUSION

Prophylactic tamsulosin did not reduce the incidence of POUR after hip and knee arthroplasty compared to placebo. The odds ratio indicates an approximately 30% decreased odds of developing POUR in the tamsulosin group, albeit not statistically significant. Tamsulosin does not appear to be effective as a prophylactic measure for reducing POUR in male hip and knee arthroplasty patients.

Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial

Background

The purpose of this study was to investigate whether patients undergoing total joint arthroplasty (TJA) require catheterization.

Methods

PubMed, EMBASE, Web of Science, Cochrane Library and China National Knowledge Infrastructure were systematically searched. All randomized controlled trials (RCTs) receiving either a urinary catheterization or no urinary catheterization were included. Meta-analysis results were assessed by RevMan 5.3 software.

Results

Seven independent RCTs were included, with a total sample size of 1533 patients, including 750 patients in the indwelling catheter group and 783 patients in the none-indwelling catheter group. Our pooled data analysis indicated that patients in the indwelling catheter group had a higher risk of urinary tract infection than patients in the none-indwelling catheter group (RR, 3.21; P = 0.0003). However, the meta-analysis indicated that there was no significant difference between the two groups in terms of urinary retention (RR, 0.67; P = 0.13), duration of the surgery (MD, − 0.37; P = 0.55), and length of hospital stay (MD, 0.15; P = 0.38).

Conclusion

Based on the current evidence, this meta-analysis showed that urinary catheterization during TJA can increase the postoperative urinary tract infection, and it may not routinely be required for the patients undergoing TJA.

Level of evidence

Level I, therapeutic study.

Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method

BACKGROUND

Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

OBJECTIVE

Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.

METHODS

Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.

RESULTS

Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1-4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.

CONCLUSION

We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.

The Most Significant Risk Factors for Urinary Retention in Fast-track Total Joint Arthroplasty are Iatrogenic

BACKGROUND

Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay.

METHODS

Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors.

RESULTS

One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001).

CONCLUSION

The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged.

Incidence and Risk Factors of Postoperative Urinary Retention and Bladder Catheterization in Patients Undergoing Fast-Track Total Joint Arthroplasty: A Prospective Observational Study on 371 Patients

BACKGROUND

Postoperative urinary retention (POUR) appears to be a common complication in lower limb joint arthroplasty; however, reports on its incidence vary. There is no general consensus on its definition and there is no scientific evidence on treatment principles. We performed a prospective observational study to establish the incidence of POUR and its risk factors, including the preoperative postvoid residual urine volume and the perioperative fluid balance, in fast-track total joint arthroplasty (TJA). The preoperative residual urine volume and the perioperative fluid balance have not been studied in previous literature in the context of TJA and POUR.

METHODS

Three hundred eighty-one patients who underwent TJA of the lower limb were observed on developing POUR according to our local treatment protocol. Data on possible risk factors for POUR were collected including the perioperative fluid balance and the preoperative residual urine volume.

RESULTS

In total, 46.3% of patients were catheterized. A preoperative postvoid urine retention is a significant predictor of catheterization for postoperative residual urine (P = .03). Spinal anesthesia was correlated with urinary retention (P = .01). There was no cause-effect relationship between POUR and the perioperative fluid balance.

CONCLUSION

This study underlines POUR as a common complication in fast-track lower limb arthroplasty, with spinal anesthesia as a risk factor. A higher preoperative residual urine volume leads to higher postoperative residual volume, but not to a higher change in urinary retention. Increased perioperative fluid administration is not correlated with the incidence of POUR. Furthermore, there seems to be little rationale for monitoring residual urine volume both preoperatively and postoperatively.

MicroRNA‑22 inhibits the proliferation and migration, and increases the cisplatin sensitivity, of osteosarcoma cells

Osteosarcoma (OS) is the major type of primary bone tumor and is associated with a poor prognosis due to chemotherapy resistance. Accumulating evidence indicates that microRNAs (miRNAs/miRs) may influence the tumor progression of OS and cell sensitivity to chemotherapy. In the present study, a total of 7 patients with OS and 7 healthy volunteers were recruited. Reverse transcription-quantitative polymerase chain reaction and ELISA were performed to determine the expression of miRNAs and mRNAs in the serum of participants. Furthermore, the biological function of miR-22 and S100A11 was examined in MG-63 cells using Cell Counting Kit-8 assays, Transwell migration assays and western blot analysis to determine the effects on cell proliferation, migration and protein expression, respectively, while MG-63 cell sensitivity to cisplatin was assessed by measuring cell viability following cisplatin treatment and calculating the half maximal inhibitory concentration (IC₅₀). Additionally, the association between miR-22 and S100 calcium-binding protein A11 (S100A11) was validated using a luciferase reporter assay. The results demonstrated that miR-22 expression was significantly reduced in patients with OS and the MG-63 OS cell line, compared with healthy volunteers and the normal osteoblast hFOB 1.19 cell line, respectively, while the expression of S100A11 was negatively associated with miR-22 levels in the MG-63 cell line. Furthermore, overexpression of miR-22 inhibited the proliferation and migratory ability of MG-63 cells, and increased the sensitivity of MG-63 cells to cisplatin treatment; however, overexpression of S100A11 partially attenuated the alterations in proliferation, migratory ability and chemosensitivity that were induced by miR-22 overexpression. In addition, it was confirmed that S100A11 is a direct target gene of miR-22 in MG-63 cells. In conclusion, to the best of our knowledge, the present study is the first to demonstrate that miR-22 may be a promising therapeutic target and may have potential as part of a combination treatment alongside chemotherapeutic agents for OS.

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia

BACKGROUND

The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia.

METHODS

Consecutive patients who underwent a primary THA without preoperative catheterization under spinal anesthesia were identified in a prospectively collected institutional patient database. All patients were monitored postoperatively for urinary retention on the basis of symptoms and the use of bladder ultrasound scans performed by a hospital technician. If necessary, straight catheterization was performed up to 2 times prior to indwelling catheter insertion.

RESULTS

One hundred eighty patients were included in the study. Six patients who required indwelling catheterization for intraoperative monitoring were excluded. Seventy-six patients experienced POUR and required straight catheterization. Fourteen patients ultimately required indwelling catheterization. One patient who was not catheterized developed a urinary tract infection versus none of the patients who were catheterized. POUR was significantly associated with intraoperative fluid volume and a history of urinary retention (P = .018 and .023, respectively). Intraoperative fluid volumes of 2025, 2325, 2875, and 3800 mL were associated with a specificity for POUR of 60%, 82.7%, 94.9%, and 98%, respectively. No significant associations were found among catheterization and gender, body mass index, American Society of Anesthesiologists class, history of polyuria, history of incontinence, postoperative oral narcotics use, or surgical duration.

CONCLUSION

Patients with a history of prior urinary retention and those who receive high volumes of intraoperative fluid volume are at higher risk for POUR following THA performed under spinal anesthesia.

Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty: A Randomized, Open-label, Controlled Trial

BACKGROUND

No evidence-based threshold exists for postoperative urinary bladder catheterization. The authors hypothesized that a catheterization threshold of 800 ml was superior to 500 ml in reducing postoperative urinary catheterization and urological complications after fast-track total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

This was a randomized, controlled, open-label trial that included patients greater than or equal to 18 yr who underwent THA or TKA in three Danish, fast-track, orthopedic departments. Consenting patients were eligible if they were cooperative and understood Danish. Participants were randomly allocated to a catheterization threshold of 500 or 800 ml, using opaque sealed envelopes. Group assignment was unmasked. Ultrasound bladder scans were performed every second hour until the first voluntary micturition, with subsequent urinary catheterization according to group assignment. The primary outcome was the number of patients catheterized before their first voluntary micturition. Thirty-day telephonic follow-up was on voiding difficulties, urinary tract infections, and readmissions.

RESULTS

Of 800 patients allocated, 721 (90%) were included in a per-protocol analysis (20 did not complete the study and 59 were excluded from the analysis). In the 500-ml group, 32.2% received catheterization (114 of 354) compared to 13.4% (49 of 367) in the 800-ml group (relative risk, 0.4; 95% CI, 0.3 to 0.6; P < 0.0001). The authors found no difference between groups in any secondary outcome.

CONCLUSIONS

In fast-track THA and TKA, a catheterization threshold of 800 ml significantly reduced the need for postoperative urinary catheterization, without increasing urological complications. This large randomized, controlled trial may serve as a basis for evidence-based guidelines on perioperative urinary bladder management.

Impact of Anterior vs Posterior Approach for Total Hip Arthroplasty on Post-Acute Care Service Utilization

BACKGROUND

Controversy exists as to which surgical approach is best for total hip arthroplasty (THA). Previous studies suggested that the tissue-sparing anterior approach should result in a more rapid recovery requiring fewer postacute services, ultimately decreasing overall episodic cost. The purpose of this cross-sectional study was to determine if any significant differences exist between the anterior vs posterior approaches on postacute care service utilization, readmissions, or episodic cost.

METHODS

Claims data from 26,773 Medicare fee-for-service beneficiaries receiving elective THAs (Medical Severity-Diagnosis Related Groups (MS-DRGs) 469/470) were analyzed. Claims data were collected from the 2-year period, January 2013 through December 2014. The posterior surgical approach was performed on 23,653 patients while 3120 patients received the anterior approach.

RESULTS

Data analysis showed negligible effect sizes in postacute care service utilization, readmission rate, and cost between the surgical approaches for elective THA (MS-DRG 469 and 470). Average THA total episode cost was negligibly higher for procedures using the anterior approach compared to the posterior approach ($22,517 and $22,068, respectively). Statistically significant differences were observed in inpatient rehab and home health cost and service utilization. However, the effect sizes of these comparisons are negligible when accounting for the large sample size. All other comparisons showed minimal and statistically insignificant variation.

CONCLUSION

The results indicate that surgical approach alone is not the primary driver of postacute care service utilization, quality outcomes, or cost. Other factors such as physician-led patient-focused care pathways, care coordination, rapid rehabilitation protocols, perioperative pain management protocols, and patient education are integral for effective patient care.

Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost

BACKGROUND

There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program.

METHODS

Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions.

RESULTS

Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%.

CONCLUSION

The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.

History of Nocturia May Guide Urinary Catheterization for Total Joint Arthroplasty

Urinary tract infection is a common complication after total knee arthroplasty (TKA) and can be related to urethral catheterization. This study attempted to determine whether nocturia could be used as an indicator of risk for postoperative urinary retention to limit the need for prophylactic catheterization in men undergoing TKA. A retrospective study was performed in a consecutive series of men undergoing TKA at a single Veterans Affairs medical center. Patients reporting 0 episodes or 1 episode of nocturia per night were not catheterized prophylactically, and patients reporting 2 or more episodes of nocturia each night were catheterized preoperatively. Of 100 consecutive patients, 51 reported no more than 1 episode of nocturia and did not undergo preoperative catheterization. Of these patients, 10 required 1 postoperative straight catheterization for urinary retention. In the 49 patients who were catheterized prophylactically, all catheters were removed on postoperative day 1. Only 1 of these patients required reinsertion of a catheter. No patient in either group was discharged with a catheter or had a urinary tract infection. Previously, the authors' standard protocol was to use a prophylactic urinary catheter for all men after TKA. In this 100-patient cohort, with this new protocol, 41 patients were not catheterized at all and 10 patients had only 1 straight catheterization. In this study, the frequency of nocturia in men undergoing TKA was an effective screening tool that safely reduced the need for an indwelling catheter in 51% of patients. [Orthopedics. 2016; 39(4):e749-e752.].

Urinary Retention is Rare After Total Joint Arthroplasty When Using Opioid-Free Regional Anesthesia

BACKGROUND

Postoperative urinary retention (POUR) is a relatively common complication after total joint arthroplasty (TJA). Based on the findings of a randomized, prospective study from our institution, we abandoned the routine use of indwelling urinary catheters in patients undergoing elective TJA using opioid-free spinal anesthesia. The aim of this study was to determine the incidence of and the risk factors for POUR in this patient population.

PATIENTS AND METHODS

A total of 842 consecutive patients underwent TJA between January 2012 and September 2014 using opioid-free spinal anesthesia in whom indwelling urinary catheters were not used. Postoperative urinary retention was defined as the inability of a patient to void that necessitated the placement of either an indwelling urinary catheter or straight catheterization. Multivariate logistic regression analysis was used to determine risk factors for developing POUR.

RESULTS

In this cohort, 79 patients (79/842; 9.3%) developed POUR. Independent risk factors for POUR were history of a benign prostatic hyperplasia (P = .02), renal disease (P = .001), longer operative time (P = .003), and age older than 67 years (P = .02). No patients in this cohort developed neurogenic bladder.

CONCLUSION

This study confirms that the routine use of indwelling urinary catheters for patients undergoing TJA using an opioid-free spinal anesthesia may not be warranted. Urinary catheters may be used selectively in patients at risk for subsequent urinary retention.

Incidence, surgical procedures, and outcomes of hip fracture among elderly type 2 diabetic and non-diabetic patients in Spain (2004-2013)

Hip fracture is a serious public health problem. We used Spanish hospital discharge data to examine trends in 2004-2013 in the incidence of hip fracture among elderly patients. We found that hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men.

INTRODUCTION

This study aimed to describe trends in the incidence of hip fracture hospitalizations, use of surgical procedures, and hospital outcomes among elderly patients with and without type 2 diabetes mellitus (T2DM) in Spain, 2004-2013.

METHODS

We selected all patients with a discharge primary diagnosis of hip fracture using the Spanish national hospital discharge database. Discharges were grouped by diabetes status: Incidences were calculated overall and stratified by diabetes status and year. We analyzed surgical procedures, length of hospital stay (LOHS), and in-hospital mortality (IHM). Multivariate analysis was adjusted by age, year, comorbidity, and in-hospital complications (IHC).

RESULTS

From 2004 to 2013, 432,760 discharges with hip fracture were identified (21.3 % suffered T2DM). Incidence among diabetic men and women increased until year 2010 and then remained stable. Diabetic women have three times higher incidence than diabetic men. Incidences and IHC were higher among patients with diabetes beside sex. The proportion of patients that underwent internal fixation increased for all groups of patients and the arthroplasty repair decreased. After multivariate analysis, IHM has improved over the study period for all patients. Suffering diabetes was associated to higher IHM in women (odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.07-1.17).

CONCLUSIONS

Hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men. In diabetic patients, incidence rates increased initially but have leveled from 2010 onwards. For all groups, the use of internal fixation has increased overtime and IHM and LOHS have decreased from 2004 to 2013.

Protocol-Based Arthroplasty: Less Is More

As a result of reading this article, physicians should be able to: 1. State an argument for, and background information on, patient-centered arthroplasty protocols. 2. Describe specific recommendations for designing a simplified arthroplasty care pathway that is reproducible in other institutions. 3. Discuss cost-effectiveness research on the latest value-delivering protocols. 4. Recognize areas of continued research and opportunities for future improvement in protocol development. Total joint arthroplasty is a successful orthopedic procedure that is performed in high volume in the United States and internationally. As economic pressures continue to mount in the US health care system, it will become increasingly important to minimize cost and improve quality and value. At the authors' institution, a protocol-based arthroplasty model is used, in many ways based on simplification of the patient care pathway. The largely evidence-based protocol has its foundation in eliminating unnecessary dogmatic practices, enhancing the patient experience, and achieving cost-effectiveness. The authors believe that a model like this can be applied to joint arthroplasty practices across the country in the future to maximize the value delivered to patients.

Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Objective

The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.

Methods

We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity.

Results

Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01).

Conclusions

Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively.

Level of Evidence

Level I.

Infection prevention in total knee arthroplasty

Periprosthetic joint infections are devastating complications that are difficult and expensive to treat and have a substantial mortality rate. A major goal of modern joint arthroplasty is to minimize these infections. Preoperative factors associated with increased risk of infection include malnutrition, diabetes mellitus, obesity (body mass index >40 kg/m(2)), and rheumatoid arthritis. Administration of appropriate antibiotics before the surgical incision is made is essential to minimize infection. The use of laminar flow rooms, proper skin preparation, limiting operating room traffic, and the use of various wound closure techniques can help to decrease infection rates. Postoperatively, optimal management of indwelling urinary catheters, blood transfusions, and wound drainage also may decrease infection rates.

Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty

Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb. In total hip arthroplasty and total knee arthroplasty, the incidence ranges from 7% to 84%. In this study, the incidence and risk factors for postoperative urinary retention were described in a cohort of 376 men undergoing total hip arthroplasty. Postoperative urinary retention was defined as the inability to void after surgery for which single or indwelling catheterization was performed. Risk factors were identified using multivariate regression analysis. Following total hip arthroplasty, 150 (39.9%) of the 376 men developed urinary retention. Patient-controlled analgesia (odds ratio, 4.10; 95% confidence interval, 1.79-9.40), use of spinal anesthesia (odds ratio, 1.79; 95% confidence interval, 1.07-2.99), and age 70 years or older (odds ratio, 1.77; 95% confidence interval, 1.06-2.95) were independent risk factors for urinary retention. Potential risk factors that were not confirmed included body mass index, American Society of Anesthesiologists physical status (Class I-III), hypertension, diabetes mellitus, prostate pathology, smoking, average pain during the first 24 hours after surgery, and length of surgery. Two of the 150 patients with urinary retention (1.3%) for which a catheter has been inserted developed a urinary tract infection vs none of the patients without urinary retention. The risk of urinary retention after total hip arthroplasty is increased in men older than 70 years, those receiving spinal anesthesia, and those with patient-controlled analgesia postoperatively.

Short-term complications in hip fracture surgery using spinal versus general anaesthesia

BACKGROUND

Spinal anaesthesia when compared to general anaesthesia has been shown to decrease postoperative morbidity in orthopaedic surgery. The aim of the present study was to assess the differences in thirty-day morbidity and mortality for patients undergoing hip fracture surgery with spinal versus general anaesthesia.

METHODS

The American College of Surgeons National Surgical Quality and Improvement Program (NSQIP) database was used to identify patients who underwent hip fracture surgery with general or spinal anaesthesia between 2010 and 2012 using CPT codes 27245 and 27244. Patient characteristics, complications, and mortality rates were compared. Univariate analysis and multivariate logistic regression were used to identify predictors of thirty-day complications. Stratified propensity scores were employed to adjust for potential selection bias between cohorts.

RESULTS

6133 patients underwent hip fracture surgery with spinal or general anaesthesia; 4318 (72.6%) patients underwent fracture repair with general anaesthesia and 1815 (27.4%) underwent fracture repair with spinal anaesthesia. The spinal anaesthesia group had a lower unadjusted frequency of blood transfusions (39.34% versus 45.49%; p<0.0001), deep vein thrombosis (0.72% versus 1.64%; p=0.004), urinary tract infection (8.87% versus 5.76%; p<0.0001), and overall complications (45.75% versus 48.97%; p=0.001). The length of surgery was shorter in the spinal anaesthesia group (55.81 versus 65.36 min; p<0.0001). After multivariate logistic regression was used to adjust for confounders, general anaesthesia (odds ratio, 1.29; 95% confidence interval, 1.14-1.47; p=0.0002) was significantly associated with increased risk for complication after hip fracture surgery. Age, female sex, body mass index, hypertension, transfusion, emergency procedure, operation time, and ASA score were risk factors for complications after hip fracture repair (all p<0.05).

CONCLUSIONS

Patients who underwent hip fracture surgery with general anaesthesia had a higher risk of thirty-day complications as compared to patients who underwent hip fracture repair with spinal anaesthesia. Surgeons should consider using spinal anaesthesia for hip fracture surgery.

Traditions and myths in hip and knee arthroplasty

BACKGROUND AND PURPOSE

Traditions are passed on from experienced surgeons to younger fellows and become "the right way to do it". Traditions associated with arthroplasty surgery may, however, not be evidence-based and may be potentially deleterious to both patients and society, increasing morbidity and mortality, slowing early functional recovery, and increasing cost.

METHODS

We identified selected traditions and performed a literature search using relevant search criteria (June 2014). We present a narrative review grading the studies according to evidence, and we suggest some lines of future research.

RESULTS

We present traditions and evaluate them against the published evidence. Preoperative removal of hair, urine testing for bacteria, use of plastic adhesive drapes intraoperatively, and prewarming of the operation room should be abandoned-as should use of a tourniquet, a space suit, a urinary catheter, and closure of the knee in extension. The safety and efficacy of tranexamic acid is supported by meta-analyses. Postoperatively, there is no evidence to support postponement of showering or postponement of changing of dressings to after 48 h. There is no evidence to recommend routine dental antibiotic prophylaxis, continuous passive motion (CPM), the use of compression stockings, cooling for pain control or reduction of swelling, flexion of at least 90 degrees as a discharge criterion following TKA, or having restrictions after THA. We present evidence supporting the use of NSAIDs, early mobilization, allowing early travel, and a low hemoglobin trigger for transfusion.

INTERPRETATION

Revision of traditions and myths surrounding hip and knee arthroplasty towards more contemporary evidence-based principles can be expected to improve early functional recovery, thus reducing morbidity, mortality, and costs.

Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review

Over the last decades the demand for hip surgery, be it elective or in a traumatic setting, has greatly increased and is projected to expand even further. Concurrent with demographic changes the affected population is burdened by an increase in average comorbidity and serious complications. It has been suggested that the choice of anesthesia not only affects the surgery setting but also the perioperative outcome as a whole. Therefore different approaches and anesthetic techniques have been developed to offer individual anesthetic and analgesic care to hip surgery patients. Recent studies on comparative effectiveness utilizing population based data have given us a novel insight on anesthetic practice and outcome, showing favorable results in the usage of regional vs general anesthesia. In this review we aim to give an overview of anesthetic techniques in use for hip surgery and their impact on perioperative outcome. While there still remains a scarcity of data investigating perioperative outcomes and anesthesia, most studies concur on a positive outcome in overall mortality, thromboembolic events, blood loss and transfusion requirements when comparing regional to general anesthesia. Much of the currently available evidence suggests that a comprehensive medical approach with emphasis on regional anesthesia can prove beneficial to patients and the health care system.

Noteworthy literature in regional anesthesia 2013

The regional anesthesia literature was quite active in the calendar year 2013. In typical fashion, the literature was composed of articles representing neuraxial analgesia, peripheral nerve blocks, patient outcomes, regional anesthesia adjuvant medications, and patient safety. The goal of this article is to summarize and present the most relevant articles from each of these arenas.