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Zimmer OM, Bloom GB, Barnes CL, Stronach BM, Mears SC, Stambough JB. The Use of General Anesthesia in Revision Joint Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00516-3. [PMID: 38788812 DOI: 10.1016/j.arth.2024.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers. METHODS We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties and 445 revision total knee arthroplasties) performed over 4 years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions. RESULTS Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day 1 and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only 6 patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80). CONCLUSIONS While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data support the notion that modern GA techniques can be successfully used in revision TJA.
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Affiliation(s)
- Olivia Moffett Zimmer
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - G Barnes Bloom
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Hanson TM, Magder LS, Pellegrini VD. Substantial Improvement in Self-Reported Mental Health Following Total Hip Arthroplasty Occurs Independent of Anesthetic Technique. J Arthroplasty 2024; 39:1220-1225.e1. [PMID: 37977307 DOI: 10.1016/j.arth.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA. METHODS Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups. RESULTS Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement. CONCLUSIONS Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.
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Affiliation(s)
- Thomas M Hanson
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent D Pellegrini
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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3
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Teulières M, Bérard E, Reina N, Marot V, Vari N, Ferre F, Minville V, Cavaignac E. Does spinal anesthesia for total hip or knee arthroplasty entail longer operating room occupancy compared to general anesthesia? Case-control study of 337 spinal versus 243 general anesthesias. Orthop Traumatol Surg Res 2024; 110:103794. [PMID: 38081357 DOI: 10.1016/j.otsr.2023.103794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Treatment protocols, including anesthesia, are constantly progressing to improve rapid early postoperative recovery in lower-limb arthroplasty. To the best of our knowledge, however, no studies compared general versus spinal anesthesia (GA vs. SA) in the surgical pathway of patients undergoing total knee or hip arthroplasty (TKA, THA). Better knowledge of the processes should improve efficacy in theater and optimize surgical planning. The present study comparing GA and SA in the operating room aimed to assess (1) theater occupancy times, and (2) times for each step in a surgery day according to type of anesthesia. HYPOTHESIS SA leads to longer theater occupancy than GA in TKA and THA. METHODS A single-center retrospective case-control study analyzed data for the period January 2019 to December 2020 in 303 TKAs (100 GA, 203 SA) and 277 THAs (143 GA, 134 SA), comparing times for all perioperative steps and particularly theater occupancy. RESULTS In TKA, occupancy did not differ between GA and SA: 98±16min versus 98±14min respectively; Δ=0min (p=0.78). In THA, occupancy was shorter with SA than GA: 117±23min versus 123±26min respectively; Δ=-6min (p=0.02). In THA, time to perform SA was longer than induction of GA: 28±13min versus 23±12min respectively; Δ=+5min (p<0.001). In TKA, time to leaving the operating room was shorter with SA than GA: 8±5min versus 14±7min respectively; Δ=-6min (p<0.001). DISCUSSION/CONCLUSION SA did not involve longer mean theater occupancy than GA for TKA, and reduced it by 6minutes for THA. LEVEL OF EVIDENCE III; case-control study.
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Affiliation(s)
- Maxime Teulières
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France
| | - Emilie Bérard
- Département d'Épidémiologie, Économie de la Santé et Santé Publique, Inserm, UPS, UMR 1295 CERPOP, Université de Toulouse, CHU de Toulouse, 37, allée Jules-Guesde, 31073 Toulouse cedex, France
| | - Nicolas Reina
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France
| | - Vincent Marot
- Unité d'Orthopédie, Hospital Nostra Senyora de Meritxell, Carrer dels Escalls, 19, 700 Escaldes-Engordany, Andorra
| | - Nicolas Vari
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France.
| | - Fabrice Ferre
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France
| | - Vincent Minville
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France
| | - Etienne Cavaignac
- Institut de l'Appareil Locomoteur, Hôpital Pierre-Paul-Riquet, CHU Toulouse Purpan, 1, place Baylac, 31000 Toulouse, France
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Zgouridou A, Kenanidis E, Potoupnis M, Tsiridis E. Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1219-1251. [PMID: 37768398 PMCID: PMC10858160 DOI: 10.1007/s00590-023-03691-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/13/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data. METHODS Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs. RESULTS One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies. CONCLUSIONS This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.
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Affiliation(s)
- Aikaterini Zgouridou
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road Efkarpia, 56403, Thessaloniki, Greece
- Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Buildings A & B, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001, Thessaloniki, Greece
| | - Eustathios Kenanidis
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road Efkarpia, 56403, Thessaloniki, Greece.
- Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Buildings A & B, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001, Thessaloniki, Greece.
| | - Michael Potoupnis
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road Efkarpia, 56403, Thessaloniki, Greece
- Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Buildings A & B, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road Efkarpia, 56403, Thessaloniki, Greece
- Centre of Orthopaedic and Regenerative Medicine (CORE), Center for Interdisciplinary Research and Innovation (CIRI)-Aristotle University of Thessaloniki (AUTH), Balkan Center, Buildings A & B, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001, Thessaloniki, Greece
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Harris AB, Valenzuela J, Andrade N, Agarwal A, Gu A, Golladay G, Thakkar S. Comparison of Pneumonia and Major Complications After Total Joint Arthroplasty With Spinal Versus General Anesthesia: A Propensity-matched Cohort Analysis. J Am Acad Orthop Surg 2024; 32:33-40. [PMID: 37603703 DOI: 10.5435/jaaos-d-23-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Spinal anesthesia (SA) allows total joint arthroplasty to be done while minimizing opioids and systemic anesthetic agents compared with general anesthesia (GA). SA has been associated with shortened postoperative recovery; however, the relationship between SA, major postoperative complications, and pneumonia (PNA) remains unclear. METHODS Patients in a large, national database who underwent total hip arthroplasty or total knee arthroplasty from 2010 to 2020 were identified. 1:1 propensity score matching was used to create matched groups of patients who underwent SA and GA. The groups were matched by age, sex, chronic obstructive pulmonary disease, smoking status, Charlson Comorbidity Index, and American Society of Anesthesiology (ASA) classification. 1:1 matching was also done among the ASA classifications as a subanalysis. RESULTS Overall, equally matched groups of 217,267 patients who underwent SA versus GA were identified. 850 patients (0.39%) developed postoperative PNA after GA versus 544 patients (0.25%) after SA ( P < 0.001). The risk of major complications was 6,922 (3.2%) in the GA group and 5,401 (2.5%) in the SA group ( P < 0.001). Similarly, the risk of unplanned postoperative reintubation was higher (0.18% versus 0.10%, P < 0.001) and mortality was higher (0.14% versus 0.09%, P < 0.001) in the GA group than in the SA group. In ASA 1 to 3 patients, the risk of PNA was 0.08% to 0.21% higher with GA than with SA. In ASA 4 patients, the risk of PNA was 0.42% higher in SA than in GA (1.92% versus 1.5%, P < 0.001) and the mortality rate was nearly doubled in GA than in SA (1.46% versus 0.77%, P = 0.017). DISCUSSION Overall, GA was associated with a small but markedly higher rate of major complications, mortality, and PNA than SA in patients undergoing total joint arthroplasty when matching for differences in comorbidities. ASA 4 patients experienced the greatest increase in absolute risk of mortality with GA versus SA.
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Affiliation(s)
- Andrew B Harris
- From the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD (Harris, and Thakkar), the California Health Sciences University, Clovis, CA (Valenzuela), the Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD (Andrade), the Department of Orthopaedic Surgery, The George Washington University, Washington, DC (Agarwal, and Gu), the Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA (Golladay), and the Orthopaedics Research Collaborative (ORC) (Harris, Gu, Golladay, and Thakkar)
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Li Z, Xu X, Zhuang Z, Lu J, Gao F, Jiang Q. Impact of spinal Anaesthesia versus general Anaesthesia on the incidence of surgical site infections after knee or hip arthroplasty: A meta-analysis. Int Wound J 2024; 21:e14369. [PMID: 37649253 PMCID: PMC10781890 DOI: 10.1111/iwj.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023] Open
Abstract
Postoperative Surgical Site Infections (SSIs) pose significant challenges to recovery after joint arthroplasty. This systematic review and meta-analysis aim to compare the incidence of SSIs after knee or hip arthroplasty under Spinal Anaesthesia (SA) versus general anaesthesia (GA). We conducted the systematic review and meta-analysis following the PRISMA guidelines, analysing data from 15 studies selected from PubMed, Embase, Web of Science, and Cochrane Library up to May 16, 2023. The analysis included studies comparing SSIs incidence in patients aged 18 years and above who underwent knee or hip arthroplasty under SA or GA. Quality assessment was performed using the Cochrane Collaboration's risk of bias tool. The effect size was calculated using random or fixed-effects models based on the observed heterogeneity. We assessed the heterogeneity between studies and conducted a sensitivity analysis. Of 1651 initially identified studies, 15 articles encompassing 353 169 patients were included in the final analysis. A total of 156 405 patients were under SA, while 196 764 received GA. The studies demonstrated substantial heterogeneity (p = 0.007, I2 = 53.7%), resulting in a random-effects model being employed. Patients receiving SA showed a 23% lower likelihood of developing SSIs postoperatively compared to GA patients (OR: 0.77, 95% CI: 0.70-0.86, p < 0.001). Sub-group analysis further confirmed these findings regardless of the type of joint arthroplasty. This meta-analysis indicated a significantly lower incidence of SSIs following knee or hip arthroplasty under SA compared to GA. Despite observed heterogeneity, the results underscore the potential benefit of SA over GA in orthopaedic surgeries to reduce the risk of SSIs.
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Affiliation(s)
- Zhizhuo Li
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xingquan Xu
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Zaikai Zhuang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Jun Lu
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fuqiang Gao
- Department of OrthopedicsPeking University China‐Japan Friendship School of Clinical MedicineBeijingChina
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
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Illescas A, Zhong H, Cozowicz C, Poeran J, Memtsoudis SG, Liu J. Anesthesia practice among joint arthroplasty patients with a previous lumbar spine surgery. J Clin Anesth 2023; 90:111222. [PMID: 37499315 DOI: 10.1016/j.jclinane.2023.111222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 06/22/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
STUDY OBJECTIVE To analyze the use of neuraxial techniques in total hip or knee arthroplasty patients who previously underwent lumbar spine surgeries. DESIGN Retrospective analysis of a national database. SETTING U.S. hospitals. PATIENTS Patients undergoing a total hip or knee arthroplasty, stratified by those with a previous lumbar fusion or decompression procedure. MEASUREMENTS Our primary outcome was the use of neuraxial anesthesia; secondary outcomes included combined complications, cardio-pulmonary complications, and prolonged length of stay. Patients with and without a history of a lumbar procedure were compared using mixed-effects regression. MAIN RESULTS Among 758,857 THAs 8961 had a history of lumbar fusion and 8599 of decompression. Among 1,387,335 TKAs 15,827 had a history of lumbar fusion and 13,652 of decompression. History of a lumbar fusion was associated with lower odds of neuraxial anesthesia use in THA (OR: 0.74 CI: 0.70-0.79, p ≤0.0001) and TKA (OR: 0.80 CI: 0.77-0.84, p ≤0.0001). CONCLUSIONS Previous lumbar fusion -but not decompression- surgery is associated with lower neuraxial anesthesia in THA/TKA patients, despite its use being universally associated with decreased length of stay. More research is needed to address the importance of neuraxial techniques in patients with prior spine surgery.
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Affiliation(s)
- Alex Illescas
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Crispiana Cozowicz
- Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Salzburg, Austria
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy/Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA.
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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Ma B, Xie H, Ling H, Ma W. Perioperative outcomes in different anesthesia techniques for patients undergoing hip fracture surgery: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:184. [PMID: 37237276 DOI: 10.1186/s12871-023-02150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Previous studies of the perioperative effects of general and regional anesthesia in adult patients undergoing effects of different anesthesia techniques on patients undergoing hip fracture surgery have not produced consistent results. The aim of this systematic review and meta-analysis was to compare the hip fracture surgery. METHODS We performed a systematic review and meta-analysis to compare the effects of general anesthesia with regional anesthesia on in-hospital mortality, 30-day mortality, postoperative pneumonia, and delirium in adult hip fracture patients (≥ 18 years). Between January 1, 2022, and March 31, 2023, a systematic search was performed for retrospective observational and prospective randomized controlled studies in PubMed, Ovid Medline, Cochrane Library, and Scopus. RESULTS Twenty-one studies including 363,470 patients showed higher in-hospital mortality in the general anesthesia group compared with regional anesthesia (OR = 1.21; 95% CI 1.13-1.29; P < 0.001, n = 191,511). The 30-day mortality (OR = 1.00; 95% CI 0.96-1.05; P = 0.95, n = 163,811), the incidence of postoperative pneumonia (OR = 0.93; 95% CI 0.82-1.06; P = 0.28, n = 36,743) and the occurrence of postoperative delirium in the two groups (OR = 0.94; 95% CI 0.74-1.20; P = 0.61, n = 2861) had no significant difference. CONCLUSION Regional anesthesia is associated with reduced in-hospital mortality. However, the type of anesthesia did not affect the occurrence of 30-day mortality, postoperative pneumonia, and delirium. A large number of randomized studies are needed in the future to examine the relationship between type of anesthesia, postoperative complications, and mortality.
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Affiliation(s)
- Bo Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, People's Republic of China
| | - Haibiao Xie
- Department of Urology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People's Republic of China
| | - Huayong Ling
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, People's Republic of China
| | - Wuhua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, People's Republic of China.
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Illescas A, Zhong H, Liu J, Cozowicz C, Poeran J, Memtsoudis SG. Neuraxial Use Among Total Knee and Hip Arthroplasty Patients With Multiple Sclerosis or Myasthenia Gravis. Anesth Analg 2023; 136:1182-1188. [PMID: 36939157 DOI: 10.1213/ane.0000000000006471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Surgical patients with preexisting neurological diseases create greater challenges to perioperative management, and choice of anesthetic is often complicated. We investigated neuraxial anesthesia use in total knee and hip arthroplasty (TKA/THA) recipients with multiple sclerosis or myasthenia gravis compared to the general population. METHODS We retrospectively analyzed patients undergoing a TKA/THA with a diagnosis of multiple sclerosis or myasthenia gravis (Premier Health Database, 2006-2019). The primary outcome was neuraxial anesthesia use in multiple sclerosis or myasthenia gravis patients compared to the general population. Secondary outcomes were length of stay, intensive care unit admission, and mechanical ventilation. We measured the association between the aforementioned subgroups and neuraxial anesthesia use. Subsequently, subgroup-specific associations between neuraxial anesthesia and secondary outcomes were measured. We report odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Among 2,184,193 TKA/THAs, 7559 and 3176 had a multiple sclerosis or myasthenia gravis diagnosis, respectively. Compared to the general population, neuraxial anesthesia use was lower in multiple sclerosis patients (OR, 0.61; CI, 0.57-0.65; P < .0001) and no different in myasthenia gravis patients (OR, 1.05; CI, 0.96-1.14; P = .304). Multiple sclerosis patients administered neuraxial anesthesia (compared to those without neuraxial anesthesia) had lower odds of prolonged length of stay (OR, 0.63; CI, 0.53-0.76; P < .0001) mirroring neuraxial anesthesia benefits seen in the general population. CONCLUSIONS Neuraxial anesthesia use was lower in surgical patients with multiple sclerosis compared to the general population but no different in those with myasthenia gravis. Neuraxial use was associated with lower odds of prolonged length of stay.
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Affiliation(s)
- Alex Illescas
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Haoyan Zhong
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
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The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy. J Orthop Trauma 2023; 37:135-141. [PMID: 36253914 DOI: 10.1097/bot.0000000000002508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. DESIGN Retrospective. SETTING Orthopedic specialty hospital. PATIENTS/PARTICIPANTS 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. MAIN OUTCOME MEASUREMENTS Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Knio ZO, Clancy PW, Zuo Z. Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis. J Clin Anesth 2023; 87:111083. [PMID: 36848778 DOI: 10.1016/j.jclinane.2023.111083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE It has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty. DESIGN Propensity-matched cohort analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021. PATIENTS Patients undergoing elective total hip arthroplasty (n = 223,060). INTERVENTIONS None. MEASUREMENTS The a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses. MAIN RESULTS The 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, -0.09 [95% CI, -0.12 to -0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021. CONCLUSIONS Total hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Paul W Clancy
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America.
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Lee S, Kim MK, Ahn E, Jung Y. Comparison of general and regional anesthesia on short-term complications in patients undergoing total knee arthroplasty: A retrospective study using national health insurance service-national sample cohort. Medicine (Baltimore) 2023; 102:e33032. [PMID: 36827051 DOI: 10.1097/md.0000000000033032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
This retrospective study compared the mortality and short-term complications according to the choice of general anesthesia or regional anesthesia in patients who underwent a total knee arthroplasty (TKA). We searched the Korean National Health Insurance Service National Sample Cohort database to analyze data from patients who received a TKA between January 2002 and December 2015. Before comparing the general and the regional anesthesia groups, the bias was reduced by propensity score matching. After matching, the mortality and complications occurring within 30 days after a TKA were compared between the 2 groups. In the database, 6491 primary TKA cases were identified. Nine hundred forty-three patients (14.5%) had a TKA performed under general anesthesia, and 5548 (85.5%) had a TKA performed under regional anesthesia. After propensity score matching, the data of 1886 patients were analyzed, with 943 patients in each group. There was no significant difference in mortality (0.32% vs 0.00%), transfusion rate (84.52% vs 84.73%, P = .8989), and length of hospital stay (50 vs 53, P = .5391) between the general and regional anesthesia groups. Most of the complications were not significantly different, but the major complications, including myocardial infarction (1.70% vs 0.64%, P = .0414) and acute renal failure (0.85% vs 0.11%, P = .0391), were higher in the general anesthesia group than in the regional anesthesia group. Also, admission to the intensive care unit (8.48% vs 2.33%, P < .0001) and total cost (₩8067, 400 vs ₩7487, 940, P = .0002) were higher in the general anesthesia group than in the regional anesthesia group. Our study found that regional anesthesia for TKA is associated with a decrease in major complications, including myocardial infarction and acute renal failure, and medical costs.
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Affiliation(s)
- SeungYoung Lee
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Seoul, South Korea
| | - Min Kyoung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Seoul, South Korea
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong hospital, Gyeonggi-do, Republic of Korea
| | - EunJin Ahn
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Seoul, South Korea
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong hospital, Gyeonggi-do, Republic of Korea
| | - YongHun Jung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Seoul, South Korea
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong hospital, Gyeonggi-do, Republic of Korea
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Spinal anesthesia is a grossly underutilized gold standard in primary total joint arthroplasty: propensity-matched analysis of a national surgical quality database. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:7. [PMID: 36759916 PMCID: PMC9910245 DOI: 10.1186/s42836-023-00163-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/09/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND There is currently no consensus regarding the optimal anesthetic technique for total hip and knee arthroplasty (THA, TKA). This study aimed to compare the utilization rates and safety of spinal vs. general anesthesia in contemporary THA/TKA practice. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a retrospective review of 307,076 patients undergoing total hip or knee arthroplasty under either spinal or general anesthesia between January 2015 and December 2018 was performed. Propensity matching was used to compare differences in operative times, hospital length of stay, discharge destination, and 30-day adverse events. The annual utilization rates for both techniques between 2011 and 2018 were also assessed. RESULTS Patients receiving spinal anesthesia had a shorter length of stay (P < 0.001) for TKA while no statistical differences in length of stay were observed for THA. Patients were also less likely to experience any 30-day complication (OR = 0.82, P <0.001 and OR = 0.92, P < 0.001 for THA and TKA, respectively) while being more likely to be discharged to home (OR = 1.46, P < 0.001 and OR = 1.44, P < 0.001 for THA and TKA, respectively). Between 2011 and 2018, spinal anesthesia utilization only increased by 1.4% for THA (P < 0.001) and decreased by 0.2% for TKA (P < 0.001), reaching 38.1% and 40.3%, respectively. CONCLUSION Spinal anesthesia remains a grossly underutilized tool despite providing better perioperative outcomes compared to general anesthesia. As orthopedic surgeons navigate the challenges of value-based care, spinal anesthesia represents an invaluable tool that should be considered the gold standard in elective, primary total hip and knee arthroplasty.
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Baldawi M, Awad ME, McKelvey G, Pearl AD, Mostafa G, Saleh KJ. Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score-Matched Cohort Analysis. J Arthroplasty 2023; 38:108-116. [PMID: 35843379 DOI: 10.1016/j.arth.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND General anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA. METHODS A large veteran's database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 6,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics. RESULTS Upon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients. CONCLUSION Using a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.
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Affiliation(s)
- Mohanad Baldawi
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan; Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan
| | - Mohamed E Awad
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan; Michigan State University College of Osteopathic Medicine, Detroit, Michigan; Wayne State University, School of Medicine, Detroit, Michigan
| | - George McKelvey
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan; Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan
| | - Adam D Pearl
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan; Wayne State University, School of Medicine, Detroit, Michigan
| | - Gamal Mostafa
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan; Wayne State University, School of Medicine, Detroit, Michigan
| | - Khaled J Saleh
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan; Michigan State University College of Osteopathic Medicine, Detroit, Michigan
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Chen FR, Quan T, Pan S, Manzi JE, Recarey M, Agarwal AR, Nicholson A, Zimmer ZR, Gulotta L, Dines JS. Anesthesia Type and Postoperative Outcomes for Patients Receiving Arthroscopic Rotator Cuff Repairs. HSS J 2022; 18:519-526. [PMID: 36263279 PMCID: PMC9527545 DOI: 10.1177/15563316221080138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023]
Abstract
Background As the indications for and the volume of arthroscopic rotator cuff repair increase, it is important to optimize perioperative care to minimize postoperative complications and health care costs. Purpose We sought to investigate if the anesthesia type used affects the rate of postoperative complications in patients undergoing arthroscopic rotator cuff repairs. Methods We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing arthroscopic rotator cuff repair from 2014 to 2018. Patients were divided into 3 cohorts: general anesthesia, regional anesthesia, and combined general plus regional anesthesia. Bivariate and multivariate analyses with stepwise technique were performed on data related to patient demographics, smoking history, functional status, medical comorbidities (ie, bleeding disorders, chronic obstructive pulmonary disease, and dialysis), and postoperative outcomes within 30 days of discharge. To assess the independent risk factors for postoperative complications, demographics and medical comorbidities were included in the multivariate analyses for any variables that derived P values <.20. Results Of 24,677 total patients undergoing arthroscopic rotator cuff repair, 15,661 (63.5%) had general anesthesia, 889 (3.6%) had regional anesthesia, and 8127 (32.9%) received combined general plus regional anesthesia. Patients who received general anesthesia rather than regional anesthesia were more frequently white (76.8% vs 74.8%, respectively) and had a medical history of hypertension (47.9% vs 41.8%, respectively), smoking (14.9% vs 12.4%, respectively), and chronic obstructive pulmonary disease (3.4% vs 1.6%, respectively). Compared with patients receiving general anesthesia, those receiving combined general plus regional were more likely to have higher American Society of Anesthesiologists class and a smoking history. Following adjustment, patients who underwent regional anesthesia had a decreased risk for postoperative admission compared with patients who had general anesthesia. Patients who underwent combined regional plus general anesthesia had decreased rates of wound complications and readmission compared with those who received general anesthesia. Conclusion Among patients undergoing arthroscopic rotator cuff repair, this retrospective study found a significantly higher rate of respiratory and cardiac comorbidities with general anesthesia compared with regional anesthesia. When controlling for these confounders, the use of regional anesthesia was still associated with lower rates of postoperative readmission compared with the general and combined subgroups. Patients receiving combined general plus regional anesthesia had decreased rates of wound complications and readmittance compared with general anesthesia. These findings may influence anesthetic choice in minimizing postoperative complications for rotator cuff repairs.
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Affiliation(s)
- Frank R. Chen
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Theodore Quan
- Department of Orthopaedic Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Sabrina Pan
- Weill Cornell Medical College, New York, NY, USA
| | | | - Melina Recarey
- Department of Orthopaedic Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Amil R. Agarwal
- Department of Orthopaedic Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | | | - Zachary R. Zimmer
- Department of Orthopaedic Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
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Cole MW, Ross BJ, Collins LK, Imonugo O, Sherman WF. The Impact of Celiac Disease on Complication Rates After Total Joint Arthroplasty: A Matched Cohort Study. Arthroplast Today 2022; 17:205-210.e3. [PMID: 36254209 PMCID: PMC9568673 DOI: 10.1016/j.artd.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022] Open
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Li T, Dong T, Cui Y, Meng X, Dai Z. Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2022; 9:937293. [PMID: 35959124 PMCID: PMC9360531 DOI: 10.3389/fsurg.2022.937293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 12/21/2022] Open
Abstract
Objective Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD. Methods Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model. Results Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63). Conclusions There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Tiantian Dong
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiangrui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Correspondence: Xiangrui Meng Zhao Dai
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Seilern Und Aspang J, Zamanzadeh RS, Schwartz AM, Premkumar A, Martin JR, Wilson JM. The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty. J Arthroplasty 2022; 37:1098-1104. [PMID: 35189289 DOI: 10.1016/j.arth.2022.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Frailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically. RESULTS A total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001). CONCLUSION Chronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.
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Affiliation(s)
| | - Ryan S Zamanzadeh
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - J Ryan Martin
- Department of Orthopaedics, Vanderbilt University, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Messina A, La Via L, Milani A, Savi M, Calabrò L, Sanfilippo F, Negri K, Castellani G, Cammarota G, Robba C, Morenghi E, Astuto M, Cecconi M. Spinal anesthesia and hypotensive events in hip fracture surgical repair in elderly patients: a meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:19. [PMID: 37386657 DOI: 10.1186/s44158-022-00047-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/20/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Spinal anesthesia (SA) is widely used for anesthetic management of patients undergoing hip surgery, and hypotension is the most common cardiovascular side effect of SA. This paper aims to assess the lowest effective dose of SA that reduces the occurrence of intraoperative hypotension in elderly patients scheduled for major lower limb orthopedic surgery. METHODS We conducted a systematic review of randomized controlled trials (RCTs) performed in elderly patients scheduled for surgical hip repair and a meta-analysis with meta-regression on the occurrence of hypotensive episodes at different effective doses of anesthetics. We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials registered. RESULTS Our search retrieved 2085 titles, and after screening, 6 were finally included in both the qualitative and quantitative analysis, including 344 patients [15% (10-28) males], with a median (25th to 75th interquartile) age of 82 (80-85). The risk of bias assessment reported "low risk" for 5 (83.3%) and "some concerns" for 1 (16.7%) of the included RCTs. The low dose of SA of [mean 6.5 mg (1.9)] anesthetic was associated with a lower incidence of hypotension [OR = 0.09 (95%CI 0.04-0.21); p = 0.04; I2 = 56.9%], as compared to the high-dose of anesthetic [mean 10.5 mg (2.4)]. CONCLUSIONS In the included studies of this meta-analysis, a mean dose of 6.5 mg of SA was effective in producing intraoperative comfort and motor block and associated with a lower incidence of hypotension as compared to a mean dose of 10.5 mg. TRIAL REGISTRATION CRD42020193627.
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Affiliation(s)
- Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Luigi La Via
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Angelo Milani
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Marzia Savi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Lorenzo Calabrò
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
| | - Katerina Negri
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
| | | | - Gianmaria Cammarota
- Department of Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Emanuela Morenghi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Via Santa Sofia 78, 95123, Catania, Italy
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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Rodkey DL, Pezzi A, Hymes R. Effects of Spinal Anesthesia in Geriatric Hip Fracture: A Propensity-Matched Study. J Orthop Trauma 2022; 36:234-238. [PMID: 34561407 DOI: 10.1097/bot.0000000000002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify whether anesthesia type is associated with surgical outcomes in geriatric patients undergoing operative treatment for a hip fracture. DESIGN Retrospective database review of prospectively collected data. PATIENTS Patients included in the American College of Surgeons National Surgical Quality Improvement Program database. All included patients were 65-89 years of age and had a hip fracture treated with internal fixation, arthroplasty, or intramedullary device. Patients were excluded for open, pathologic, stress-related, or periprosthetic hip fractures. INTERVENTION Use of spinal anesthesia (SA) or general anesthesia (GA). MAIN OUTCOME MEASUREMENTS Complications, mortality, and discharge destination. RESULTS A total of 23,649 cases met inclusion and exclusion criteria and were successfully matched using propensity score matching: 15,766 GA and 7883 SA. The odds of sustaining a complication were 21% lower in the SA group compared with those in the GA group (odds ratio SA/GA 0.791; 95% confidence interval, 0.747-0.838). The 30-day mortality rate was not correlated with SA or GA choice. Patients who underwent SA were significantly more likely to be discharged to home (odds ratio SA/GA 1.65; 95% confidence interval, 1.531-1.773). CONCLUSIONS No mortality difference exists between patients undergoing SA and those undergoing GA for hip fracture surgery. For patients undergoing hip fracture surgery with SA, there is lower 30-day complication profile and higher discharge to home rate compared with those undergoing GA. Both anesthesia modalities may be acceptable. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel L Rodkey
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Alexandra Pezzi
- Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC ; and
| | - Robert Hymes
- Department of Orthopaedic Surgery, INOVA Fairfax, Falls Church, VA
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21
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Yap E, Wei J, Webb C, Ng K, Behrends M. Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study. Reg Anesth Pain Med 2022; 47:294-300. [PMID: 34992150 PMCID: PMC8961758 DOI: 10.1136/rapm-2021-103189] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/09/2021] [Indexed: 11/04/2022]
Abstract
Background Neuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given the selection of healthier patients. Objective To compare the effects of neuraxial versus general anesthesia on outcomes following ambulatory hip and knee arthroplasty. Methods Multicentered retrospective cohort study in ambulatory hip or knee arthroplasty patients between January 2017 and December 2019. Primary endpoint examined 30-day major postoperative complications (mortality, myocardial infarction, deep venous thromboembolism, pulmonary embolism, stroke, and acute renal failure). Results Of 11 523 eligible patients identified, 10 003 received neuraxial anesthesia, while 1520 received general anesthesia. 30-day major complications did not differ between neuraxial anesthesia and general anesthesia groups (1.8% vs 2.3%; aOR=0.85, CI: 0.56 to 1.27, p=0.39). There was no difference in 30-day minor complications (surgical site infection, pneumonia, urinary tract infection; 3.3% vs 4.1%; aOR=0.83, CI: 0.62 to 1.14, p=0.23). The neuraxial group demonstrated reduced pain and analgesia requirements and had less postoperative nausea and vomiting (PONV). Median recovery room length of stay was shorter by 52 min in the general anesthesia group, but these patients were more likely to fail same day discharge (33% vs 23.4%; p<0.01). Conclusion Anesthesia type was not associated with an increased risk for complications. However, neuraxial anesthesia improved outcomes that predict readiness for discharge: patients had less pain, required less opioids, and had a lower incidence of PONV, thus improving the rate of same day discharge. Trial registration number NCT04203732.
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Affiliation(s)
- Edward Yap
- Department of Anesthesia, The Permanente Medical Group, South San Francisco, California, USA .,Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Julia Wei
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Christopher Webb
- Department of Anesthesia, The Permanente Medical Group, South San Francisco, California, USA.,Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Kevin Ng
- Department of Anesthesia, The Permanente Medical Group, Walnut Creek, California, USA
| | - Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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22
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Suneja N, Kong RM, Tiburzi HA, Shah NV, von Keudell AG, Harris MB, Saleh A. Racial Differences in Orthopedic Trauma Surgery. Orthopedics 2022; 45:71-76. [PMID: 35021034 DOI: 10.3928/01477447-20220105-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].
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23
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Evaluation of the rate of post-operative dislocation in patients with ipsilateral valgus knee deformity after primary total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:1507-1514. [DOI: 10.1007/s00264-022-05372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
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24
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Wei C, Gu A, Muthiah A, Fassihi SC, Sculco PK, Nunley RM, Bernstein BA, Liu J, Berger JS. Neuraxial anaesthesia is associated with improved outcomes and reduced postoperative complications in patients undergoing aseptic revision total hip arthroplasty. Hip Int 2022; 32:221-230. [PMID: 33241947 DOI: 10.1177/1120700020975749] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND As the incidence of primary total hip arthroplasty (THA) continues to increase, revision THA (rTHA) is becoming an increasingly common procedure. rTHA is widely regarded as a more challenging procedure, with higher complication rates and increased medical, social and economic burdens when compared to its primary counterpart. Given the complexity of rTHA and the projected increase in incidence of these procedures, patient optimisation is becoming of interest to improve outcomes. Anaesthetic choice has been extensively studied in primary THA as a modifiable risk factor for postoperative outcomes, showing favourable results for neuraxial anaesthesia compared to general anaesthesia. The impact of anaesthetic choice in rTHA has not been studied previously. METHODS A retrospective study was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent rTHA between 2014 and 2017 were divided into 3 anaesthesia cohorts: general anaesthesia, neuraxial anaesthesia, and combined general-regional (neuraxial and/or peripheral nerve block) anaesthesia. Univariate and multivariate analyses were used to analyse patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post-hoc analysis. RESULTS In total, 5759 patients were identified. Of these, 3551 (61.7%) patients underwent general anaesthesia, 1513 (26.3%) patients underwent neuraxial anaesthesia, and 695 (12.1%) patients underwent combined general-regional anaesthesia. On multivariate analysis, neuraxial anaesthesia was associated with decreased odds for any-one complication (OR 0.635; p < 0.001), perioperative blood transfusion (OR 0.641; p < 0.001), and extended length of stay (OR 0.005; p = 0.005) compared to general anaesthesia. CONCLUSIONS Relative to those receiving general anaesthesia, patients undergoing neuraxial anaesthesia are at decreased risk for postoperative complications, perioperative blood transfusions, and extended length of stay. Prospective controlled trials should be conducted to verify these findings.
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Affiliation(s)
- Chapman Wei
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alex Gu
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Arun Muthiah
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington DC, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University at St Louis, St. Louis, MO
| | - Brad A Bernstein
- Department of Anesthesiology, St Louis University School of Medicine, St. Louis, MO, USA
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Jeffrey S Berger
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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25
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Danilkowicz R, Levin JM, Crook B, Long JS, Vap A. Analysis of Risk Factors, Complications, Reoperations, and Demographics Associated With Open and Arthroscopic Rotator Cuff Repair: An Analysis of a Large National Database. Arthroscopy 2022; 38:737-742. [PMID: 34508821 DOI: 10.1016/j.arthro.2021.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/11/2021] [Accepted: 09/01/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the national trends in arthroscopic and open rotator cuff repair surgery and the associated demographics, complications, and risk factors specific to each procedure. METHODS A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) dataset between the years 2007 and 2018. Patients were identified using Common Procedural Terminology codes for open and arthroscopic rotator cuff repair. Variables collected including basic demographics, procedural, and outcome specific variables as available through the NSQIP repository. Appropriate statistical measures were used to compare the groups, with the χ2 test used for categorical variables and t test for continuous variables. RESULTS The arthroscopic cohort comprised 39,013 patients; the open group consisted of 8,664. Reported arthroscopic and open cases increased significantly between 2007 and 2018 from 135 to 7,269 and 65 to 1,168, respectively. Average operative time for arthroscopic procedure was 89 minutes and 76 minutes for open. The open group consisted of a slightly greater percentage of smokers, 18.3% versus 15.2%, and patients with diabetes, 18.2% versus 15.9%, both of which were statistically significant (P < .001). Open cases had an odds ratio of 3.05 for superficial infections and 7.40 for deep infections, both of which were statistically significant (P < .001). The open cohort also had an odds ratio of 1.71 for unplanned readmissions when compared with the arthroscopic cohort, which was also statistically significant (P < .001). CONCLUSIONS According to the NSQIP database, the increase in arthroscopic procedures is significantly outpacing the increase in open procedures during this study period, which matches the trends seen in previous studies. Patients with diabetes and who smoke also represent a greater risk group for postoperative complications when undergoing open surgery. These findings suggest that perhaps the decision to pursue one technique over the other may be influenced both by provider preference and patient-related factors. LEVEL OF EVIDENCE III, retrospective comparative trial.
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Affiliation(s)
| | - Jay M Levin
- Department of Orthopedics, Duke University Medical Center
| | - Bryan Crook
- Duke University School of Medicine, Durham, North Carolina
| | - Jason S Long
- Department of Orthopedics, Duke University Medical Center.
| | - Alexander Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health Systems, Richmond, Virginia, U.S.A
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Outcomes of Tourniquet-Less Revision Total Knee Arthroplasty: A Matched Cohort Analysis. J Am Acad Orthop Surg 2021; 29:e1343-e1352. [PMID: 34037577 DOI: 10.5435/jaaos-d-20-00796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/03/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the visibility of the surgeon's field of view. This study aims to evaluate the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA. METHODS We conducted a retrospective review of 1,904 consecutive patients who underwent revision TKA. Propensity score-based matching was done to adjust for baseline differences in patient demographics and procedure details. RESULTS Propensity score matching resulted in a cohort of 548 revision total joint arthroplasty patients, 274 (50.0%) of whom were tourniquet patients matched to 274 (50.0%) tourniquet-less patients. Multivariate regression analyses demonstrated that, compared with the tourniquet-less cohort, the tourniquet cohort had significantly less intraoperative (413.7 to 353.2 mL, P < 0.01) and total perioperative (1,548.7 to 1,417.8 mL, P < 0.01) blood loss. However, no significant differences were present in total perioperative (8.4%, 6.6%, P = 0.43) transfusion rates. The tourniquet cohort had increased length of stay (3.2 to 3.7 days, P < 0.001) and 30-day readmissions (P = 0.04). DISCUSSION This study demonstrated that although omitting the tourniquet in revision TKA leads to markedly increased perioperative blood loss, notable differences in perioperative transfusion rates were not observed. Furthermore, revision TKA without tourniquet use was associated with reduced postoperative length of stay, 30-day readmissions, and increased range of flexion.
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27
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Gurney JK, McLeod MA, Campbell D, Dennett E, Jackson S, Koea J, Lash N, Ongley D. Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use. Anaesth Intensive Care 2021; 50:178-188. [PMID: 34871516 DOI: 10.1177/0310057x211050934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.
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Affiliation(s)
- Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Melissa A McLeod
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Douglas Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Elizabeth Dennett
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Sarah Jackson
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Jonathan Koea
- Department of Surgery, Waitematā District Health Board, Auckland, New Zealand
| | - Nicholas Lash
- Department of Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Dick Ongley
- Department of Anaesthesia, Canterbury District Health Board, Christchurch, New Zealand
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Panula VJ, Alakylä KJ, Venäläinen MS, Haapakoski JJ, Eskelinen AP, Manninen MJ, Kettunen JS, Puhto AP, Vasara AI, Elo LL, Mäkelä KT. Risk factors for prosthetic joint infections following total hip arthroplasty based on 33,337 hips in the Finnish Arthroplasty Register from 2014 to 2018. Acta Orthop 2021; 92:665-672. [PMID: 34196592 PMCID: PMC8635657 DOI: 10.1080/17453674.2021.1944529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Periprosthetic joint infection (PJI) is a devastating complication and more information on risk factors for PJI is required to find measures to prevent infections. Therefore, we assessed risk factors for PJI after primary total hip arthroplasty (THA) in a large patient cohort.Patients and methods - We analyzed 33,337 primary THAs performed between May 2014 and January 2018 based on the Finnish Arthroplasty Register (FAR). Cox proportional hazards regression was used to estimate hazard ratios with 95% confidence intervals (CI) for first PJI revision operation using 25 potential patient- and surgical-related risk factors as covariates.Results - 350 primary THAs were revised for the first time due to PJI during the study period. The hazard ratios for PJI revision in multivariable analysis were 2.0 (CI 1.3-3.2) for ASA class II and 3.2 (2.0-5.1) for ASA class III-IV compared with ASA class I, 1.4 (1.1-1.7) for bleeding > 500 mL compared with < 500 mL, 0.4 (0.2-0.7) for ceramic-on-ceramic bearing couple compared with metal-on-polyethylene and for the first 3 postoperative weeks, 3.0 (1.6-5.6) for operation time of > 120 minutes compared with 45-59 minutes, and 2.6 (1.4-4.9) for simultaneous bilateral operation. In the univariable analysis, hazard ratios for PJI revision were 2.3 (1.7-3.3) for BMI of 31-35 and 5.0 (3.5-7.1) for BMI of > 35 compared with patients with BMI of 21-25.Interpretation - We found several modifiable risk factors associated with increased PJI revision risk after THA to which special attention should be paid preoperatively. In particular, high BMI may be an even more prominent risk factor for PJI than previously assessed.
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Affiliation(s)
- Valtteri J Panula
- Department of Orthopaedics and Traumatology, Turku University Hospital, and University of Turku, Turku
| | - Kasperi J Alakylä
- Department of Orthopaedics and Traumatology, Turku University Hospital, and University of Turku, Turku;,CONTACT Kasperi J ALAKYLÄ
| | - Mikko S Venäläinen
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku
| | | | | | | | - Jukka S Kettunen
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio
| | - Ari-Pekka Puhto
- Division of Operative Care, Department of Orthopaedic and Trauma Surgery, Oulu University Hospital, Oulu
| | | | - Laura L Elo
- Turku Bioscience Centre, University of Turku and Åbo Akademi University, Turku
| | - Keijo T Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, and University of Turku, Turku
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29
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Hur ES, Bohl DD, Della Valle CJ, Villalobos F, Gerlinger TL. Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty. J Knee Surg 2021; 36:491-497. [PMID: 34768290 DOI: 10.1055/s-0041-1739146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.
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Affiliation(s)
- Edward S Hur
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Felipe Villalobos
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Tad L Gerlinger
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Herndon CL, Levitsky MM, Ezuma C, Sarpong NO, Shah RP, Cooper HJ. Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty. Arthroplast Today 2021; 11:6-9. [PMID: 34401423 PMCID: PMC8358092 DOI: 10.1016/j.artd.2021.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 05/14/2021] [Accepted: 05/25/2021] [Indexed: 01/05/2023] Open
Abstract
Background The choice of anesthesia plays a significant role in the success of total joint arthroplasty (TJA). Isobaric bupivacaine spinal anesthesia is often used. However, dosing of bupivacaine has not been extensively studied and is usually at the discretion of the treating anesthesiologist and surgeon. The goal of this study was to determine what, if any, effect the dose of bupivacaine spinal anesthesia had on perioperative outcomes in TJA. Methods A total of 761 TJAs performed with bupivacaine spinal anesthesia by arthroplasty surgeons were retrospectively reviewed. Perioperative outcomes evaluated were operation duration, estimated blood loss, length of stay (LOS) in the postanesthesia care unit, hospital LOS, discharge disposition, episodes of intraoperative hypotension, postoperative nausea and vomiting, and missed physical therapy sessions because of postoperative symptoms of hypotension. A Student’s t-test was used for continuous variables, and a chi-squared test was used for categorical variables. Results Of the 761 patients, 499 (65.6%) received 15 mg isobaric bupivacaine while 262 (34.4%) received <15 mg (range = 7.5-14.5 mg, median = 12.5 mg). With the numbers available in this cohort, lower doses of bupivacaine were not associated with any significant differences between groups for any of the studied perioperative outcomes, including proportion of patients discharged home or LOS. Conclusion Dosage of bupivacaine spinal anesthetic did not affect perioperative outcomes. Bupivacaine may not have a dose-related response curve in this regard, and if seeking to perform same-day or outpatient TJA, other agents may need to be considered, rather than smaller doses of bupivacaine.
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Affiliation(s)
- Carl L Herndon
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew M Levitsky
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Chimere Ezuma
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Nana O Sarpong
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - H John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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31
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Mufarrih SH, Qureshi NQ, Schaefer MS, Sharkey A, Fatima H, Chaudhary O, Krumm S, Baribeau V, Mahmood F, Schermerhorn M, Matyal R. Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia. Eur J Vasc Endovasc Surg 2021; 62:476-484. [PMID: 34303598 DOI: 10.1016/j.ejvs.2021.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/19/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary and secondary lower extremity amputation, performed for patients with lower extremity arterial disease, is associated with increased post-operative morbidity. The aim of the study was to assess the impact of regional anaesthesia vs. general anaesthesia on post-operative pulmonary complications. METHODS A retrospective analysis of 45 492 patients undergoing lower extremity amputation between 2005 and 2018 was conducted using data from the American College of Surgeons National Safety Quality Improvement Program database. Multivariable logistic regression was carried out to assess differences in primary outcome of post-operative pulmonary complications (pneumonia or respiratory failure requiring re-intubation) within 48 hours and 30 days after surgery between patients receiving regional (RA) or general anaesthesia (GA). Secondary outcomes included post-operative blood transfusion, septic shock, re-operation, and post-operative death within 30 days. RESULTS Of 45 492 patients, 40 026 (88.0%) received GA and 5 466 (12.0%) RA. Patients who received GA had higher odds of developing pulmonary complications at 48 hours (2.1% vs. 1.4%; adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI] 1.09 - 1.78; p = .007) and within 30 days (6.3% vs. 5.9%; aOR 1.15, 95% CI 1.09 - 1.78; p = .039). The odds of blood transfusions (aOR 1.11, 95% CI 1.02 - 1.21; p = .017), septic shock (aOR 1.29, 95% CI 1.03 - 1.60; p = .025) and re-operation (OR 1.26, 95% CI 1.03 - 1.53; p = .023) were also higher for patients who received GA vs. patients who received RA. No difference in mortality rate was observed between patients who received GA and those who received RA (5.7% vs. 7.1%; odds ratio 0.95, 95% CI 0.84 - 1.07). CONCLUSION A statistically significant reduction in pulmonary complications was observed in patients who received RA for lower extremity amputation compared with GA.
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Affiliation(s)
- Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Nada Qaisar Qureshi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Omar Chaudhary
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Santiago Krumm
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Vincent Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Marc Schermerhorn
- Department of Vascular and Endovascular Surgery, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
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Outcome of Spinal Versus General Anesthesia in Revision Total Hip Arthroplasty: A Propensity Score-Matched Cohort Analysis. J Am Acad Orthop Surg 2021; 29:e656-e666. [PMID: 32947347 DOI: 10.5435/jaaos-d-20-00797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/18/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Spinal anesthesia has been previously shown to offer improved patient outcomes compared with general anesthesia in revision total knee arthroplasty. This study aimed to evaluate the potential differences in perioperartive and postoperative outcomes in revision total hip arthroplasty (THA) between spinal or general anesthesia. METHODS A total of 2,656 consecutive patients who underwent revision THA were evaluated. Propensity-score-adjusted multivariate logistic regression analyses were applied to control for intergroup variability and evaluate the differences in outcomes and complications with anesthesia type. RESULTS Propensity score matching resulted in 1:1 matching with 265 patients in each anesthesia cohort. Multivariate analyses demonstrated that patients administered general anesthesia had a significantly longer procedure time (174.8 versus 161.3, P < 0.01), higher intraoperative (402.6 versus 305.5 mL, P < 0.01), and total perioperative blood loss (1802.2 versus 1,684.2 mL,P < 0.01). In addition, patients administered general anesthesia were found to have higher odds for two or more inhospital complications (odds ratio, 4.51, P < 0.01) and extended length of stay (odds ratio, 2.45, P = 0.02). DISCUSSION Our study shows that propensity-matched patients who received spinal anesthesia for revision THA exhibited notable reduction in surgical time, perioperative blood loss, and complications compared with patients who received general anesthesia, suggesting that spinal anesthesia is a viable alternative to general anesthesia in revision THA.
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Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures. Eur J Trauma Emerg Surg 2021; 48:4569-4576. [PMID: 34050773 PMCID: PMC8164052 DOI: 10.1007/s00068-021-01704-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/13/2021] [Indexed: 11/23/2022]
Abstract
Purpose Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs. Methods A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018—these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts. Results Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579). Conclusion With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01704-1.
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Müller-Wirtz LM, Volk T. Big Data in Studying Acute Pain and Regional Anesthesia. J Clin Med 2021; 10:jcm10071425. [PMID: 33916000 PMCID: PMC8036552 DOI: 10.3390/jcm10071425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022] Open
Abstract
The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, the utilization of big data in acute pain and regional anesthesia research has considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia.
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Affiliation(s)
- Lukas M. Müller-Wirtz
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Saarland, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Correspondence: (L.M.M.-W.); (T.V.)
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Saarland, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Correspondence: (L.M.M.-W.); (T.V.)
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Hong GJ, Wilson LA, Liu J, Memtsoudis SG. Tranexamic Acid Administration is Associated With a Decreased Odds of Prosthetic Joint Infection Following Primary Total Hip and Primary Total Knee Arthroplasty: A National Database Analysis. J Arthroplasty 2021; 36:1109-1113. [PMID: 33127237 DOI: 10.1016/j.arth.2020.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/29/2020] [Accepted: 10/04/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) for the reduction of blood loss in orthopedic surgery is coming into greater adoption. Because TXA administration lowers the incidence of blood transfusion and of hematoma formation, risk factors for infection, we asked whether TXA use might be associated with a lower incidence of periprosthetic joint infection (PJI) following orthopedic surgery. METHODS We queried the Premier Healthcare database for ICD-9 codes corresponding to elective inpatient primary total hip replacement (THR) or total knee replacement (TKR) from 2012 to 2016, TXA administration on the day of surgery, and PJI during the hospital stay or within 90 days. We performed a multilevel multivariable logistic regression (SAS version 9.4. SAS Institute, Cary, NC) to determine if TXA administration or other covariates were a significant predictor of infection. RESULTS Among 914,990 total joint arthroplasty patients, 46.0% received TXA on the day of surgery. 0.13% developed PJI within 90 days. After adjusting for patient and hospital-related covariates, TXA use was associated with significantly lower odds of PJI within 90 days of surgery (OR 0.49 [0.69, 0.91]). CONCLUSION Administration of TXA on the day of surgery in total knee and total hip arthroplasty was associated with a statistically significant decreased odds of PJI in the first 90 days. We therefore conclude that TXA might play an important role in our attempts to decrease PJI after joint arthroplasty. The exact mechanisms and ideal dosage by which TXA can contribute to such a reduction need further study.
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Affiliation(s)
- Genewoo J Hong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medical College, New York, NY
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medical College, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medical College, New York, NY; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
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Eklund SE, Vodonos A, Ryan-Barnett SM. Changing practice to increase rates of spinal anaesthesia for total joint replacement. J Perioper Pract 2021; 32:83-89. [PMID: 33611968 DOI: 10.1177/1750458920970145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neuraxial anaesthesia for lower extremity total joint replacement surgery has several advantages over general anaesthesia; however, we encountered resistance to routine use of spinal anaesthesia and standardised analgesic regimens at our large, tertiary hospital. Our Perioperative Surgical Home led to multidisciplinary education and enhanced communication to change practice, with the purpose of increasing rates of neuraxial anaesthetics for these surgeries. METHODS Team members from anaesthesia, nursing and surgery participated in the development and adoption of the care pathway. After implementation, we performed a retrospective analysis to examine the impact of the pathway on primary anaesthetic choice. Data were analysed using Student's t-test and interrupted time series analysis. RESULTS The rate of neuraxial anaesthetics increased following implementation of the total joint pathway. CONCLUSION With multidisciplinary collaboration, we were able to change practice towards spinal anaesthesia, despite a large and diverse group of practitioners.
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Affiliation(s)
- Susan E Eklund
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Alina Vodonos
- Clinical Research Center Soroka University Medical Center, Beersheva, Israel
| | - Sheila M Ryan-Barnett
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA
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Total Hip Arthroplasty Revision Surgery: Impact of Morbidity on Perioperative Outcomes. J Arthroplasty 2021; 36:676-681. [PMID: 32854995 DOI: 10.1016/j.arth.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Primary and revision total hip arthroplasty (THA) is increasingly performed in patients with high comorbidity burden. Its predominantly negative effects on outcomes are well understood in primary THA; however, the effects of morbidity on revision THA are unknown. Since revision procedures account for about 10% of the total surgical volume, we set out to investigate the effects of physical health status on perioperative outcomes in this setting. METHODS We queried our prospectively collected institutional database for patients who underwent revision THA at our institution (Orthopedic University Hospital Friedrichsheim, Frankfurt) between 2007 and 2011. Patients were classified according to American Society of Anesthesiologists (ASA) category and number of comorbidities. Subsequently, their impact on perioperative parameters was analyzed. RESULTS Our database revealed 294 cases of revision THA during the study period. Patients preoperatively classified as ASA 3 and 4 showed significantly higher rates of intraoperative and postoperative complications, transfusions, prolonged intensive care unit (ICU) stay, and total length of stay (LOS) compared to patients classified as ASA 1 and 2. Similarly, patients with >3 comorbidities presented with significantly elevated postoperative complications, ICU stay, and LOS. Particularly, preoperative cardiac diseases were associated with increased blood loss, transfusions, duration of surgery, postoperative complications, ICU stay, LOS, and re-revisions. CONCLUSION Poor physical health condition is associated with negative perioperative outcomes in revision THA. Especially cardiac comorbidities are linked to unfavorable outcomes, which have important implications for assessment of perioperative risk.
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Khan IA, Noman R, Markatia N, Castro G, Rodriguez de la Vega P, Ruiz-Pelaez J. Comparing the Effects of General Versus Regional Anesthesia on Postoperative Mortality in Total and Partial Hip Arthroplasty. Cureus 2021; 13:e12462. [PMID: 33552779 PMCID: PMC7854317 DOI: 10.7759/cureus.12462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose Total hip arthroplasty (THA) and partial hip arthroplasty (PHA) are performed in patients with hip joint dysfunction such as osteoarthritis or hip fractures and are associated with complications including mortality. There is a lack of evidence in the literature regarding whether the type of anesthesia (regional vs. general) is associated with increased postoperative mortality in patients undergoing hip arthroplasty. The present study compares early postoperative mortality between general or regional anesthesia administered to patients undergoing either THA or PHA. Methods A retrospective cohort was assembled using the 2015-2016 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients undergoing hip arthroplasty under general or regional anesthesia were included. Patients were excluded if receiving any other type of anesthesia, as well as having an American Society of Anesthesiologists (ASA) physical status classification score ≥ 4, preoperative acute renal failure, severe congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or ascites. Adjusted odds of 30 days all-cause postoperative mortality according to the type of anesthesia were estimated by fitting multiple logistic regression models that included potential confounders and effect modifiers. Results A total of 60,897 patients were included in the study. Given that the interaction between the type of anesthesia and the type of arthroplasty was statistically significant, separated models were fitted for each type of arthroplasty. There was no evidence of an association between type of anesthesia and postoperative mortality in hip arthroplasty patients regardless of whether the arthroplasty was partial (odds ratio {OR} = 0.85; confidence interval {CI} 0.59-1.22) or total (OR = 0.68; CI 0.43-1.08). Conclusion The overall early postoperative mortality in adult hip arthroplasty patients is low in the absence of risk factors such as severe CHF, COPD, ascites, acute renal failure, and ASA score of 4 or higher. Our findings suggest there is no association between the type of anesthesia received (general vs. regional) and early postoperative mortality rates in patients undergoing hip arthroplasty, regardless of type (total vs. partial).
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Affiliation(s)
- Irfan A Khan
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
| | - Raihan Noman
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
| | - Nabeel Markatia
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
| | - Grettel Castro
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
| | - Pura Rodriguez de la Vega
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
| | - Juan Ruiz-Pelaez
- Department of Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, USA
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Vrontis K, Tsinaslanidis G, Drosos GI, Tzatzairis T. Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:646-655. [PMID: 33313343 DOI: 10.22038/abjs.2020.45651.2249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.
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Affiliation(s)
| | | | - Georgios I Drosos
- Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Dragana, Greece
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Comparison of Perioperative Complications Between Anterior Fusion and Posterior Fusion for Osteoporotic Vertebral Fractures in Elderly Patients: Propensity Score-Matching Analysis Using Nationwide Inpatient Database. Clin Spine Surg 2020; 33:E586-E592. [PMID: 32349061 DOI: 10.1097/bsd.0000000000000992] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study using a nationwide inpatient database. OBJECTIVE The objective of this study was to evaluate the perioperative complications post-anterior fusion (AF) and posterior fusion (PF) for osteoporotic vertebral fractures (OVFs) with a large National Inpatient Database. SUMMARY OF BACKGROUND DATA OVF of the thoracolumbar spine often occur because of bone fragility and low-energy trauma in elderly patients. Though AF and PF are 2 representative surgical methods, there have been few studies focusing on perioperative complications of each method. MATERIALS AND METHODS The total 2446 (AF: 435 cases, PF: 2011 cases) patients who diagnosed thoracic or lumbar OVF and received either AF or PF were included from 2012 to 2016 with the Diagnosis Procedure Combination (DPC) database. After one-to-one propensity score-matching, total 866 cases were analyzed to evaluate systemic and local complication rates, reoperation rates, costs, and mortality. RESULTS A total of 433 pairs were made between the surgical procedures after matching. At least 1 systemic complication was seen in 26.6% of the AF group compared with 16.9% of the PF group (P=0.001). Specifically, the incidence of pulmonary embolism (P=0.045), urinary tract infection (P=0.012), and pleurisy (P=0.004) were significantly higher in the AF group. Blood transfusion (P=0.007) and the operation for systemic complications (P=0.020) were required more often in the AF group. The cost for hospitalization was also higher in the AF group (P<0.001). There were no differences in the mortality rates between the 2 groups. CONCLUSIONS More systemic complications were observed in the AF group. Surgeons need to take careful consideration of the merits and demerits described in this study when deciding the surgical method for OVF. LEVEL OF EVIDENCE Level 3.
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A Comparison of Neuraxial and General Anesthesia for Thirty-Day Postoperative Outcomes in United States Veterans Undergoing Total Knee Arthroplasty. J Arthroplasty 2020; 35:3138-3144. [PMID: 32641270 DOI: 10.1016/j.arth.2020.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study is to investigate which anesthetic technique is superior on 30-day outcomes after primary total knee arthroplasty (TKA) in United States veteran patients. To our knowledge, this is the first account from the Veterans Health Administration comparing the effects of different anesthesia modalities in patients undergoing TKA. METHODS The Veterans Affairs Surgical Quality Improvement Program database was utilized to analyze patients undergoing primary TKA during the period of 2008-2015. Subjects were divided into 2 cohorts based on the method of surgical anesthesia used: general anesthesia or neuraxial anesthesia. Propensity score matching was utilized to avoid possible selection bias between the 2 cohorts when assessing patient demographics and comorbidities. The 2 groups were analyzed for 30-day postoperative complications, using multivariable logistic regression techniques to evaluate independent associations between anesthetic method and postoperative outcomes. RESULTS All Veterans Affairs patients undergoing primary TKA under general anesthesia (n = 32,363) and neuraxial anesthesia (n = 14,395) within the study period were included in this study. Following propensity score matching, multivariable analysis revealed significantly lower risks of cardiovascular (adjusted odds ratio [AOR] 0.74, 95% confidence interval [CI] 0.6-0.88, P < .001), respiratory (AOR 0.75, 95% CI 0.57-0.97, P = .03), and renal complications (AOR 0.62, 95% CI 0.4-0.9, P = .01) in patients receiving neuraxial anesthesia compared to those receiving general anesthesia. Neuraxial anesthesia was also associated with reduced hospital stay and lower odds of prolonged hospitalization (AOR 0.85, 95% CI 0.8-0.9, P < .001). CONCLUSION Veteran patients undergoing TKA under neuraxial anesthesia had reduced postoperative complications and decreased hospitalization stay compared to patients undergoing general anesthesia.
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Kagan R, Zhao S, Stone A, Johnson AJ, Huff T, Schabel K, Woodworth GE, Ivie RMJ. Spinal anesthesia in a designated block bay for total joint arthroplasty: improving operating room efficiency. Reg Anesth Pain Med 2020; 45:975-978. [DOI: 10.1136/rapm-2020-101773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/22/2020] [Accepted: 08/27/2020] [Indexed: 01/07/2023]
Abstract
BackgroundCreating highly efficient operating room (OR) protocols for total joint arthroplasty (TJA) is a challenging and multifactorial process. We evaluated whether spinal anesthesia in a designated block bay (BBSA) would reduce time to incision, improve first case start time and decrease conversion to general anesthesia (GA).MethodsRetrospective cohort study on the first 86 TJA cases with BBSA from April to December 2018, compared with 344 TJA cases with spinal anesthesia performed in the OR (ORSA) during the same period. All TJA cases were included if the anesthetic plan was for spinal anesthesia. Patients were excluded if circumstances delayed start time or time to incision (advanced vascular access, pacemaker interrogation, surgeon availability). Data were extracted and analyzed via a linear mixed effects model to compare time to incision, via a Wilcoxon rank-sum test to compare first case start time, and via a Fisher’s exact test to compare conversion to GA between the groups.ResultsIn the mixed effect model, the BBSA group time to incision was 5.37 min less than the ORSA group (p=0.018). The BBSA group had improved median first case start time (30.0 min) versus the ORSA group (40.5 min, p<0.0001). There was lower conversion to GA 2/86 (2.33%) in the BBSA group versus 36/344 (10.47%) in the ORSA group (p=0.018). No serious adverse events were noted in either group.ConclusionsBBSA had limited impact on time to incision for TJA, with a small decrease for single OR days and no improvement on OR days with two rooms. BBSA was associated with improved first case start time and decreased rate of conversion to GA. Further research is needed to identify how BBSA affects the efficiency of TJA.
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Song J, Qiao Y, Zhou Q, Zhang X. Fascia iliaca compartment block for analgesia in total hip replacement: A randomized controlled study protocol. Medicine (Baltimore) 2020; 99:e22158. [PMID: 32925776 PMCID: PMC7489678 DOI: 10.1097/md.0000000000022158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pain management after the total joint arthroplasty is still challenging, but worthy of attention, because good pain management can improve the outcomes of patient. It is still controversial whether fascia iliaca compartment block (FICB) can effectively decrease the opioid consumption and pain after total hip replacement (THR) owing to the number of published investigations is small. The purpose of this present study is to assess the efficacy and safety of FICB for postoperative analgesia after THR. METHODS This is a single center, placebo-controlled randomized trial which is performed in accordance with the SPIRIT Checklist for randomized studies. It was authorized via the Chifeng Municipal Hospital institutional review committee (H2020-19-8). 100 patients undergoing THR will be included in this study. Patients are randomly divided into 2 groups: FICB group or Non-FICB group, FICB with 5mgmL of epinephrine and 40 mL of ropivacaine 0.2%. Primary outcomes are pain score at different time point. Visual analog scale is used to assess the pain (10: the maximum possible pain and 0: absent pain). The secondary outcomes are the postoperative complications, length of hospital stay and total consumption of opioid. All the needed analyses are implemented through utilizing SPSS for Windows Version 15.0. RESULTS Figure 1 will show the primary and secondary outcomes. CONCLUSION This trial can provide an evidence for the use of FICB for analgesia after THR.
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Affiliation(s)
| | - Yan Qiao
- Department of neurology, Chifeng Municipal Hospital, Inner Mongolia, China
| | - Qi Zhou
- Department of Anesthesiology
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Wilson JM, Schwartz AM, Farley KX, Bradbury TL, Guild GN. Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty. J Arthroplasty 2020; 35:2488-2494. [PMID: 32444236 DOI: 10.1016/j.arth.2020.04.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient. METHODS This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts. RESULTS 105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001). CONCLUSIONS Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.
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Outcomes of Elective Total Hip Arthroplasty in Nonagenarians and Centenarians. J Arthroplasty 2020; 35:2149-2154. [PMID: 32312644 DOI: 10.1016/j.arth.2020.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Nonagenarians and centenarians are among the fastest growing demographics in the United States. Although consequent demand for joint replacement is projected to rise precipitously, outcomes of total hip arthroplasty (THA) have seldom been studied in this population. METHODS A retrospective cohort of patients undergoing primary THA was established using the 2008-2017 American College of Surgeons National Quality Improvement Program. Propensity scores were used to match 858 patients aged 90 or older to 858 patients aged 65-89, controlling for demographic factors and comorbidities. Thirty-day outcomes were compared between matched age cohorts using multiple regression modeling. RESULTS Statistically equivalent 30-day rates of surgical infection (P = .73), pneumonia (P = .39), deep venous thrombosis/thrombophlebitis (P = .55), pulmonary embolism (P = .69), stroke (P = .73), myocardial infarction (P = .44), cardiac arrest (P = .69), and sepsis (P = .77) were observed between matched age cohorts, although nonagenarians and centenarians were significantly more likely to experience urinary tract infection (2.8% vs 0.9%, P = .004). In addition, matched patients aged 90 or older were more likely to have longer hospital stays (3.52 vs 2.81 days, P < .001) and be discharged to a nonhome facility (75.4% vs 34.6%, P < .001) but were at no higher than 30-day risk of reoperation (P = .45), readmission (P = .23), or mortality (P = .59). CONCLUSION Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. Patient comorbidity profiles, rather than age, should principally guide shared clinical decision making.
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Paziuk TM, Luzzi AJ, Fleischman AN, Goswami K, Schwenk ES, Levicoff EA, Parvizi J. General vs Spinal Anesthesia for Total Joint Arthroplasty: A Single-Institution Observational Review. J Arthroplasty 2020; 35:955-959. [PMID: 31983564 DOI: 10.1016/j.arth.2019.11.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/09/2019] [Accepted: 11/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) can be successfully carried out under general (GA) or spinal anesthesia (SA). The existing literature does not adequately illustrate which technique is optimal. The purpose of this study is to prospectively compare the effects of anesthesia technique on TJA outcomes. METHODS This 2-year, prospective, observational study was conducted at a single institution where patients receiving primary TJA were consecutively enrolled. Patients were contacted postoperatively to assess for any 90-day complications. The primary outcome of the study was the overall complication rate. RESULTS A total of 2242 patients underwent total hip arthroplasty (n = 656; 29.26%) or total knee arthroplasty (n = 1586; 70.74%) between 2015 and 2017. Of these procedures, 1325 (59.10%) were carried out under SA and 917 (40.90%) were carried out under GA. Patients in the GA cohort had higher mean Charlson Comorbidity Index scores (0.05 SA vs 0.09 GA; P < .05) and higher average body mass index (29.35 SA vs 30.24 GA; P < .05). On multivariate analysis, patients in the SA cohort had a significantly lower overall complication rate relative to their GA counterparts (7.02% vs 10.14%; odds ratio, 0.66; 95% confidence interval, 0.49-0.90; P < .05). In addition, length of stay in the GA cohort was significantly longer (2.43 [SD, 1.62] vs 2.18 [SD, 0.88] days; P < .01) and a larger percentage of GA patients were discharged to a nursing facility (32.28% vs 25.06%; odds ratio, 0.55; 95% confidence interval, 0.44-0.70; P < .05). CONCLUSION Our study demonstrates that SA for TJA is associated with a decrease in overall complications and healthcare resource utilization.
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Affiliation(s)
- Taylor M Paziuk
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew J Luzzi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew N Fleischman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Eric S Schwenk
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Eric A Levicoff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Yazdi H, Klement MR, Hammad M, Inoue D, Xu C, Goswami K, Parvizi J. Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty. J Arthroplasty 2020; 35:840-844. [PMID: 31722855 DOI: 10.1016/j.arth.2019.10.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated preoperative anemia to be a strong risk factor for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). Allogeneic blood transfusion can be associated with increased risk of PJI after primary and revision TJA. Tranexamic acid (TXA) is known to reduce blood loss and the need for allogeneic blood transfusion after TJA. The hypothesis of this study is that administration of intravenous TXA would result in a reduction in PJI after TJA. METHODS An institutional database was utilized to identify 6340 patients undergoing primary TJA between January 1, 2013 and June 31, 2017 with a minimum of 1-year follow-up. Patients were divided into 2 groups based on whether they received intravenous TXA prior to TJA or not. Patients who developed PJI were identified. All PJI patients met the 2018 International Consensus Meeting definition for PJI. A multivariate regression analysis was performed to identify variables independently associated with PJI. RESULTS Of the patients included, 3683 (58.1%) received TXA and 2657 (41.9%) did not. The overall incidence of preoperative anemia was 16%, postoperative blood transfusion 1.8%, and PJI 2.4%. Bivariate analysis showed that patients who received TXA were significantly at lower odds of infection. After adjusting for all confounding variables, multivariate regression analysis showed that TXA is associated with reduced PJI after primary TJA. CONCLUSION TXA can help reduce the rate of PJI after primary TJA. This protective effect is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion.
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Affiliation(s)
- Hamidreza Yazdi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Mitchell R Klement
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Hammad
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Daisuke Inoue
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Chi Xu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. J Am Acad Orthop Surg 2020; 28:e213-e221. [PMID: 31478916 DOI: 10.5435/jaaos-d-19-00156] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We compared the following 30-day outcomes for total knee arthroplasty (TKA) and total hip arthroplasty in spinal anesthesia (SA) versus general anesthesia (GA) (1) mortality, (2) major and minor complication rates, and (3) discharge disposition. METHODS From 2011 to 2016, the American College of Surgeons National Surgical Quality Improvement Program database contained 45,871 SA total hip arthroplasties and 65,092 receiving GA. There were 80,077 SA TKAs and 103,003 GA TKAs. Adjusted multivariate logistic regression evaluated associations between anesthesia type and 30-day outcomes. RESULTS Anesthesia modality was not associated with 30-day mortality (P > 0.05). The GA cohorts were at a greater risk for any complication, major complications, and minor complications (P < 0.05). Patients who received GA were at an increased risk for nonhome discharge. CONCLUSION Patients who undergo total joint arthroplasty with SA experience fewer 30-day complications and are less likely to have a nonhome discharge than those with GA.
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Kaiser HA, Saied NN, Kokoefer AS, Saffour L, Zoller JK, Helwani MA. Incidence and prediction of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation and 30-day mortality in non-cardiac surgical patients. PLoS One 2020; 15:e0225939. [PMID: 31967987 PMCID: PMC6975552 DOI: 10.1371/journal.pone.0225939] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 11/17/2019] [Indexed: 12/03/2022] Open
Abstract
Background The incidence, prediction and mortality outcomes of intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR) in surgical patients are under investigated and have not been studied concurrently in a single study. Methods A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program data between 2008 and 2012. Firth’s penalized logistic regression was used to study the incidence and identify risk factors for intra- and postoperative CPR and 30-day mortality. simplified prediction model was constructed and internally validated to predict the studied outcomes. Results Among about 1.86 million non-cardiac operations, the incidence rate of intraoperative CPR was 0.03%, and for postoperative CPR was 0.33%. The 30-day mortality incidence rate was 1.25%. The incidence rate of events decreased overtime between 2008–2012. Of the 29 potential predictors, 14 were significant for intraoperative CPR, 23 for postoperative CPR, and 25 for 30-day mortality. The five strongest predictors (highest odd ratios) of intraoperative CPR were the American Society of Anesthesiologists (ASA) physical status, Systemic Inflammatory Response Syndrome (SIRS)/sepsis, surgery type, urgent/emergency case and anesthesia technique. Intraoperative CPR, ASA, age, functional status and end stage renal disease were the most significant predictors for postoperative CPR. The most significant predictors of 30-day mortality were ASA, age, functional status, SIRS/sepsis, and disseminated cancer. The predictions with the simplified five-factor model performed well and was comparable to the full prediction model. Postoperative cardiac arrest requiring CPR, compared to intraoperative, was associated with much higher mortality. Conclusions The incidence of cardiac arrest requiring CPR in surgical patients decreased overtime. Risk factors for intraoperative CPR, postoperative CPR and perioperative mortality are overlapped. We proposed a simplified approach compromised of five-factor model to identify patients at high risk. Postoperative, compare to intraoperative, cardiac arrest requiring CPR was associated with much higher mortality.
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Affiliation(s)
- Heiko A. Kaiser
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- Department of Anesthesiology and Pain Medicine; Inselspital, Bern University Hospital; University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Nahel N. Saied
- Department of Anesthesiology and Critical Care, University of Arkansas Medical Sciences, Little Rock, Arkansas, United States of America
| | - Andreas S. Kokoefer
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, Paracelsus Medical University Salzburg, Strubergasse, Salzburg, Austria
| | - Lina Saffour
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
| | - Jonathan K. Zoller
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
| | - Mohammad A. Helwani
- Department of Anesthesiology, Washington University, St. Louis, Missouri, United States of America
- * E-mail:
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Mishra K, Fernstrum A, Mahran A, Sidagam V, Adamic B, Shekar A, Calaway A, Nguyen C, Ponsky L, Bukavina L. Epidural Anesthesia is Associated With Increased Complications in Cystectomy Patients: A NSQIP Analysis. Urology 2020; 138:77-83. [PMID: 31954167 DOI: 10.1016/j.urology.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/28/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify differences in short-term outcomes and readmission rates in cystectomy patients managed with general anesthesia compared to those undergoing general anesthesia and adjuvant epidural anesthesia. METHODS Utilizing the National Surgical Quality Inpatient Program database, patients who underwent a cystectomy with ileal conduit between 2014 and 2017 were included. Patients were further subdivided based on additional anesthesia modality; general anesthesia vs general anesthesia plus epidural anesthesia. Propensity score-matching was used to adjust for baseline differences between cohorts using 1:1 caliper width of 0.15 for the propensity score through the nearest neighbor. Stepwise multivariable logistic regression was used to identify preoperative and intraoperative predictors associated with 30-day procedure related readmission, complications, and length of stay. RESULTS About 2956 patients met our inclusion and exclusion criteria and eligible for propensity score matching. Compared to general anesthesia, adjuvant epidural anesthesia showed an increased odds of procedure related complications (adjusted Odds Ratio (aOR): 1.264, 95% CI: 1.019-1.567, P = .033). There was an increased trend for development of pulmonary emboli (13 [1.8%] vs 4 [0.5%], P = .051) in the adjuvant epidural cohort. Combined general with epidural anesthesia demonstrated no difference in length of stay, readmission, or reoperation rate in comparison to general anesthesia alone. CONCLUSION Cystectomy patients who underwent general anesthesia plus epidural anesthesia demonstrated a higher percentage of any procedural related complication without change in postoperative stay, reoperation rate, or readmission rate compared to patients undergoing general anesthesia alone.
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Affiliation(s)
- Kirtishri Mishra
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Austin Fernstrum
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Amr Mahran
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH
| | - Vasu Sidagam
- University Hospitals Cleveland Medical Center, Department of Perioperative Medicine, Cleveland, OH
| | | | - Anjali Shekar
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Adam Calaway
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Carvell Nguyen
- Case Western Reserve University School of Medicine, Cleveland, OH; Metro Health Medical Center, Cleveland, OH
| | - Lee Ponsky
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Laura Bukavina
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
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