The impact of blood management on length of stay after primary total knee arthroplasty

The Use of Bone Wax in Hemostatic Control for Total Knee and Hip Arthroplasties: A Systematic Review

Background/Objectives: Blood loss can be a serious complication in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Various methods are used by surgeons to achieve hemostatic control in these patients. Complications are associated with perioperative blood loss. In this systematic review, we examined the efficacy of using bone wax to control bleeding in patients undergoing THA and TKA. Methods: The PRISMA model was used to systematically identify and aggregate articles for this study. The PubMed and EMBASE databases were used to search individual studies that examined the use of bone wax in THA or TKA. After applying the search term "bone wax", 2478 articles were initially identified. After inclusion and exclusion criteria were applied, three articles were aggregated for this systematic review. Results: The use of bone wax in THA and TKA decreased blood loss in patients undergoing these operations. Postoperative blood loss following surgery was lower in the bone wax groups compared to the control groups as well. Patients in the bone wax groups also required fewer blood transfusions than those who did not receive bone wax. Conclusions: Bone wax appears to be another modality that can be used by physicians to maintain hemostatic control in THA or TKA patients. Reduced blood loss and transfusion rates in surgery can increase patient outcomes. More studies are needed to examine the efficacy of bone wax in comparison with other hemostatic tools.

Impact of intra- and extramedullary alignment on blood loss in total knee arthroplasty: a retrospective study

BACKGROUND

There is a scarcity of scientific data regarding the correlation between alignment techniques during total knee arthroplasty (TKA) and blood loss as well as transfusion rates. This study's hypothesis posited that intramedullary-aligned (IM) TKA exhibits higher blood loss and transfusion rates when contrasted with extramedullary-aligned (EM) TKA.

METHODS

We conducted a retrospective examination of 883 patients who underwent total knee arthroplasty (TKA) in 2021 at a solitary orthopedic center in Germany. These patients were divided into two groups based on their tibial alignment technique: extramedullary alignment and intramedullary tibial alignment.

RESULTS

In the intramedullary tibial alignment (IM) group, we observed a blood loss of 0.91 L, while in the extramedullary tibial alignment (EM) group, the blood loss was 0.89 L. These values did not demonstrate a significant difference (p = 0.69). Transfusion rates were 0.99% in the IM group and 0.21% in the EM group, and there was no significant distinction between them (Chi-squared test: p > 0.05).

CONCLUSION

We observed no statistically significant variance in blood loss between the IM and EM groups. Likewise, there was no substantial disparity in transfusion rates between these groups. It can be concluded that the selection of a knee arthroplasty system incorporating either intramedullary tibial alignment or extramedullary alignment does not significantly impact blood loss.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis

BACKGROUND

Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care.

OBJECTIVES

To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology.

SEARCH METHODS

We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received.

MAIN RESULTS

We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials).

AUTHORS' CONCLUSIONS

We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.

Understanding factors that impact the length of stay after total hip arthroplasty - A national in-patient sample-based study

Background

Total hip arthroplasty (THA) is increasingly used every year; however, there is currently limited information on factors that impact the length of stay (LOS) following the procedure. Longer LOS following THA is met with an increase in the cost of care, necessitating studies to identify factors that may impact LOS.

Methods

In this retrospective study, we used the Nationwide Inpatient Sample (NIS) database from 2016 to 2019 to analyze the preoperative comorbidities and postoperative complications that impact the LOS following THA. We divided our cohort into patients with a LOS greater than two days, and patients with a LOS less than two days.

Results

A total of 367,890 patients were identified in the NIS database who underwent THA during the study period. Of this cohort, 112,288 (30.52%) patients were identified as having a LOS greater than two days, while the remaining 255,602 (69.48%) patients were patients who had a LOS less than two days. Multivariate analysis demonstrated several pre-operative factors, such as diabetes, systemic lupus erythematosus, organ transplant, dialysis, the human immunodeficiency virus, chronic kidney disease, and Parkinson's disease, were independently associated with a higher risk of a LOS greater than two days. The subsequent multivariate analysis for post-operative variables demonstrated that acute renal failure, myocardial infarction, blood loss anemia, blood transfusion, pulmonary embolism, deep vein thrombosis, periprosthetic fracture, periprosthetic mechanical complications, periprosthetic infections, and wound dehiscence were all independently associated with a higher risk of a LOS greater than two days.

Conclusions

Several pre-operative comorbidities and postoperative complications were found to increase the likelihood of a LOS greater than two days. In addition, the group with a LOS greater than two days incurred a higher cost of care. This information is useful for providers to make informed decisions regarding patient care and resource utilization for patients undergoing THA, potentially reducing LOS.

Hospital characteristics and perioperative complications of Hispanic patients following reverse shoulder arthroplasty-a large database study

BACKGROUND

Hispanic patients are the youngest and fastest-growing ethnic group in the USA. Many of these patients are increasingly met with orthopedic issues, often electing to undergo corrective procedures such as reverse shoulder arthroplasty (RSA). This patient population has unique medical needs and has been reported to have higher incidences of perioperative complications following major procedures. Unfortunately, there is a lack of information on the hospitalization data and perioperative complications in Hispanic patients following procedures such as RSA. This project aimed to query the Nationwide Inpatient Sample (NIS) database to assess patient hospitalization information, demographics, and the prevalence of perioperative complications among Hispanic patients who received RSA.

METHODS

Information from 2016-2019 was queried from the NIS database. Demographic information, incidences of perioperative complications, length of stay, and costs of care among Hispanic patients undergoing RSA were compared to non-Hispanic patients undergoing RSA. A subsequent propensity matching was conducted to consider preoperative comorbidities.

RESULTS

The query of NIS identified 59,916 patients who underwent RSA. Of this sample, 2,656 patients (4.4%) were identified to be Hispanic, while the remaining 57,260 patients (95.6%) were found to belong to other races (control). After propensity matching, Hispanic patients had a significantly longer LOS (median = 1.4 days) than the patients in the control group (median = 1.0, P < 0.001). The Hispanic patients (89,168.5 USD) had a significantly higher cost of care than those in the control group (67,396.1 USD, P < 0.001). In looking at postoperative complications, Hispanic patients had increased incidences of acute renal failure (Hispanics: 3.1%, control group: 1.1%, P = 0.03) and blood loss anemia (Hispanics: 12.7%, control group: 10.9%, P = 0.03).

CONCLUSIONS

Hispanic patients had significantly longer lengths of stay, higher costs of care, and higher rates of perioperative complications compared to the control group. For patients who are Hispanic and undergoing RSA, this information will aid doctors in making comprehensive decisions regarding patient care and resource allocation.

The effect of cocaine on patients undergoing total hip arthroplasty

BACKGROUND

Cocaine use has surged in the past decade, with 4.8 million Americans (1.7% of the population greater than 12) reporting use in 2021, leading to a healthcare burden of 1.3 billion dollars. Cocaine users experience prolonged hospital stays, higher costs, worse surgical outcomes, increased risk of medical conditions, and inflammation-related osteoarthritis. The study aims to identify factors influencing length of stay, costs, and perioperative complications in cocaine users undergoing total hip arthroplasty (THA) to reduce these risks.

METHODS

This study utilized the NIS database, providing comprehensive information on patient demographics, length of stay, hospital costs, and complications. Statistical analyses were conducted using SPSS software, including propensity matching and significance testing, to compare outcomes between cocaine users (CU) and non-cocaine users (NCU) undergoing total hip arthroplasty.

RESULTS

After propensity matching, cocaine users had a significantly longer LOS (4.8 days) in comparison to non-cocaine users (2.6 days) (p < 0.001). Similarly, the CU group had a larger of care (87984.9) than the NCU group (69149.2) (p < 0.001). Cocaine users had significantly higher rates of blood loss anemia (OR: 3.24, 95% CI: 2.21, 4.73), blood loss anemia (OR: 1.59, 95% CI: 1.12, 2.24), blood transfusion (OR: 2.23, 95% CI: 1.04, 4.78), periprosthetic dislocation (OR: 6.57, 95% CI: 1.47, 29.32), and periprosthetic infection (OR: 4.59, 95% CI: 1.54, 13.68) than patients in the non-cocaine user's group.

CONCLUSION

Cocaine users had a significantly longer length of stay, higher costs of care, and an increased number of post-operative complications compared to non-cocaine users. These data contribute to understanding the potential ramifications of cocaine users undergoing THA.

Establishment and evaluation of a predictive model for length of hospital stay after total knee arthroplasty: A single-center retrospective study in China

Background

Total knee arthroplasty (TKA) is the ultimate option for end-stage osteoarthritis, and the demand of this procedure are increasing every year. The length of hospital stay (LOS) greatly affects the overall cost of joint arthroplasty. The purpose of this study was to develop and validate a predictive model using perioperative data to estimate the risk of prolonged LOS in patients undergoing TKA.

Methods

Data for 694 patients after TKA collected retrospectively in our department were analyzed by logistic regression models. Multi-variable logistic regression modeling with forward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated.

Results

Eight independent predictors were identified: non-medical insurance payment, Charlson Comorbidity Index (CCI) ≥ 3, body mass index (BMI) &gt; 25.2, surgery on Monday, age &gt; 67.5, postoperative complications, blood transfusion, and operation time &gt; 120.5 min had a higher probability of hospitalization for ≥6 days. The model had good discrimination [area under the curve (AUC), 0.802 95% CI, 0.754–0.850]] and good calibration (p = 0.929). A decision curve analysis proved that the nomogram was clinically effective.

Conclusion

This study identified risk factors for prolonged hospital stay in patients after TKA. It is important to recognize all the factors that affect hospital LOS to try to maximize the use of medical resources, optimize hospital LOS and ultimately optimize the care of our patients.

Length of Hospital Stay after Total Knee Arthroplasty: A Correlation Study on 1200 Patients

In countries with a high average population age, total knee arthroplasty is still carried out in an inpatient setting. The roadmap to performing major surgery on an outpatient basis passes through the understanding of those perioperative features that correlate with higher lengths of hospital stay (LOS). A retrospective database of 1200 patients was reviewed for retrieving preoperative and perioperative factors including anthropometric and demographic data, comorbidities, preoperative laboratory assessment, and surgical time. Considering the LOS as a discrete series, data were analyzed by means of logistic regression with multiple univariate and multivariate models. The results showed a median length of hospital stay of 3 (IQR 3, 4) days. According to multiple univariate analysis, arterial hypertension (p = 0.008), diabetes mellitus (p = 0.028), CCI score (p < 0.001), ASA score (p = 0.006), surgical time (p < 0.001) and intraoperative blood loss (p < 0.001) were significantly associated with the duration of hospital stay in days. Moreover, preoperative hemoglobin value was inversely correlated to the LOS (p = 0.008). Multivariate analysis showed a significant correlation between LOS and surgical time and intraoperative blood loss. Many factors influence the permanence of the inpatient and acting on those variables, by stabilizing comorbidities and optimizing laboratory values, may reduce the overall healthcare burden.

An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India

BACKGROUND:

Significant blood loss and requirement of allogenic blood transfusion during or after total knee replacement (TKR) have been reported. Incidence of blood transfusion in TKR is highly variable and depends on several factors. We investigated the blood utilization in patients undergoing TKR in our hospital and depicted the important risk factors that determine the need of allogenic blood transfusion in primary unilateral TKR.

MATERIALS AND METHODS:

The study included 1241 consecutive patients undergoing primary unilateral total knee arthroplasty. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patient and disease details were obtained from patient file and hospital information system. Compatibility test was performed in blood bank before blood reservation following mandatory guidelines. Details of test, blood issue, and blood transfusion were documented in the blood bank.

RESULTS:

Of 1241 enrolled patients, 1069 (86.2%) were female. The median age of patients was 66 years with mean preoperative hemoglobin of 9.9 g/dL. Allogenic blood transfused was needed in 223 (17.9%) patients. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions. Risk factors such as gender, American Society of Anesthesiologists score, preoperative hemoglobin, and intraoperative and postoperative blood losses were significantly associated with blood transfusion.

CONCLUSION:

The risk factors determining blood transfusion in TKR vary between studies, however, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. In addition, each center may develop specific blood management strategy to rationalize blood transfusion in TKR and overall successful care in TKR.

Beneficial and limiting factors in return to work after primary total knee replacement: Patients' perspective

BACKGROUND:

Return to work (RTW) is an important outcome in Total Knee Arthroplasty (TKA). At present, 70–80%of TKA patients return to work within three to six months.

OBJECTIVE:

What are patients’ perspectives regarding beneficial and limiting factors in RTW after TKA?

METHODS:

Focus groups were formed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Three major topics were explored: 1. What was beneficial for RTW after TKA; 2. What was limiting for RTW after TKA; and 3. What additional care would benefit RTW after TKA?

RESULTS:

Data saturation was reached after four focus groups, comprising 17 participants—nine men and eight women (median age 58, range 52–65). The focus group study identified four main themes that contributed to a successful RTW namely rehabilitation (medical) like post-operative physical therapy, patient characteristics (personal), like motivation to RTW, occupational characteristics (work-related) like build-up in work tasks and medical support (medical) like availability of a walker or crutches.

CONCLUSION:

According to participants, factors within the following four themes can contribute to a successful return to work: occupational, patient, rehabilitation and medical care. Incorporating these factors into the integrated care pathway for the “young” TKA patients may increase the chances of a successful RTW.

Identifying factors predicting prolonged rehabilitation after simultaneous bilateral total knee arthroplasty: a retrospective observational study

Background

Rehabilitation is an effective procedure for promoting functional recovery after simultaneous bilateral total knee arthroplasty (TKA); however, it has been cited as a significant economic burden of medical care. We hypothesized that preoperative factors, including age, sex, body mass index, living alone, the knee society function score (KSS), the American society of anesthesiologists (ASA) class, hemoglobin (Hb), albumin level, mean range of motion, and the Kellgren–Lawrence grade, would predict prolonged rehabilitation utilization.

Methods

In total, 191 patients undergoing simultaneous bilateral TKA in a single hospital were enrolled. The successful compliance group included patients who completed their rehabilitation program and could return to their residence within 3 weeks after surgery (n = 132), whereas the delayed group included the remaining patients (n = 59). Logistic regression analysis was performed using preoperative factors. A prediction scoring system was created using the regression coefficients from the logistic regression model.

Results

Logistic regression analysis revealed that age (β = − 0.0870; P <  0.01) and Hb (β = 0.34; P <  0.05) were significantly associated with prolonged rehabilitation programs, whereas body mass index, living alone, KSS score, and ASA class were not significantly associated with successful completion of rehabilitation programs; however, these factors contributed to the prediction scoring formula, which was defined as follows: \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\displaystyle \begin{array}{l}\mathrm{Score}=10-\left(0.09\times \mathrm{age}\right)-\left(0.09\times \mathrm{body}\ \mathrm{mass}\ \mathrm{index}\right)-\left(0.56\times \mathrm{living}\ \mathrm{alone}\ \right[\mathrm{alone}:1,\\ {}\mathrm{others}:0\left]\right)+\left(0.03\times \mathrm{KSS}\ \mathrm{stairs}\right)+\left(0.34\times \mathrm{Hb}\right)-\left(1.1\times \mathrm{ASA}\ \mathrm{class}\right).\end{array}} $$\end{document}Score=10-0.09×age-0.09×body mass index-(0.56×living alone[alone:1,others:0])+0.03×KSSstairs+0.34×Hb-1.1×ASAclass.

The C-statistic for the scoring system was 0.748 (95% confidence interval, 0.672–0.824). The positive and negative likelihood ratios were 2.228 (95% CI, 1.256–3.950) and 0.386 (95% CI, 0.263–0.566), respectively. These results showed an increase of 15–20% and a decrease of 20–25% in the risk of prolonged rehabilitation. The optimal cutoff point for balancing sensitivity and specificity was 3.5, with 66.6% sensitivity and 78.0% specificity.

Conclusions

Older age and lower preoperative Hb were significantly associated with prolonged rehabilitation programs. We defined a new scoring formula using preoperative patient factors to predict prolonged rehabilitation utilization in patients undergoing simultaneous bilateral TKA.

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty

BACKGROUND

Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA.

METHODS

Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours.

RESULTS

A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours.

CONCLUSION

This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

Optimal Length of Stay Following Total Joint Arthroplasty to Reduce Readmission Rates

BACKGROUND

Length of stay (LOS) following total joint arthroplasty (TJA) continues to decrease. The effects of this trend on readmission risk and total cost are unclear. We hypothesize that optimal LOS following TJA minimizes index hospitalization, early readmission risk, and total cost.

METHODS

Retrospective data from the South Carolina Department of Revenue and Fiscal Affairs was reviewed for patients who underwent primary TJA in South Carolina from 2000 to 2015 (n = 172,760). Data for readmissions within 90 days were included. Severity of illness was estimated by Elixhauser score (EH). Index LOS is defined as the surgery and the subsequent hospital stay.

RESULTS

Patients with more significant medical comorbidities (EH ≥ 4) had significantly longer LOS than healthier patients (4.0 vs 3.4 days, P < .001). Independent of EH, readmitted patients had a significantly longer index LOS than those never readmitted (4.3 vs 3.6 days, P < .001). For healthier patients (EH ≤ 3), each additional inpatient day increased readmission risk, while among sicker patients, staying 2 days vs 1 day was protective against readmission risk. Since 2000, the total index cost of TJA has doubled and average cost per inpatient day has tripled, but readmission rates remain essentially unchanged (7.4% to 7.0%).

CONCLUSION

Increased LOS was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal LOS after TJA is highly influenced by the patient's overall health. Despite a 300% increase in TJA daily cost, readmission rate has changed minimally over the last 15 years.

Perioperative predictors of prolonged length of hospital stay following total knee arthroplasty: a retrospective study from a single center in China

Background

Decreasing the length of hospital stay is an ideal course of action to appropriately allocate medical resources. The aim of this retrospective study was to identify perioperative factors that may decrease the length of hospital stay (LOS).

Methods

In this study, we collected the data on 1112 patients who underwent primary total knee arthroplasty surgery (TKAs) at our institution from Jan 1, 2011 to Nov 31, 2017. Based on the published literature, 16 potential factors (12 preoperative variables, 1 intraoperative variable, and 3 postoperative variables) were investigated. The patients requiring a hospital stay longer than the mean LOS (8 days) were defined as patients with a prolonged LOS. The factors with a P value less than 0.1 in the univariate analysis were further analysed in a multivariate model. An ordinal regression was used to determine independent risk factors for a prolonged LOS.

Results

The mean LOS was 8.3 days (±4.3), with a range of 2 to 30 days. Sixteen variables were analysed by univariate analysis, and 11 of them had p < 0.1 and were included in the multivariable model. Finally, 9 factors were found to be associated with a prolonged LOS. Among the 9 variables, 2 were surgery-related factors (operative time and intraoperative blood loss), and 3 were patient-related factors (age, ASA classification and neurological comorbidities).

Conclusion

In this study, we found that the clinical protocol, complications, the patient’s age, the ASA classification, neurological comorbidities, the operative time, the ward, intraoperative blood loss and the surgeon were all factors contributing to a prolonged LOS. In clinical practice, these factors provide important information for the surgeon and are useful for identifying patients with a high risk of a prolonged LOS.

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361-367.].

The association of mental health disease with perioperative outcomes following femoral neck fractures

INTRODUCTION

Mental illness in the United States is a growing problem, leading to significant implications for those effected as well as direct and indirect costs to the health care system. The association between psychiatric comorbidity and increased risk of perioperative adverse events has previously been described following elective orthopedic surgery, however, there is a paucity of literature evaluating the correlation between mental health disease and outcomes in patients in an orthopedic trauma setting.

METHODS

Utilizing data from the US National Hospital Discharge Survey, all patients undergoing surgery for femoral neck fracture were identified between the years 1990 and 2007. The association of depression, anxiety, dementia and schizophrenia on surgical outcomes were then analyzed using univariate regression analysis.

RESULTS

A cohort of 2,432,931 patients was identified. All psychiatric comorbidities were associated with a lower rate of routine discharge home following surgery (p < 0.001). Schizophrenia was associated with increased odds of any adverse event (p < 0.001), acute post-operative mechanical complications (p < 0.001) and increased length of stay (p < 0.001).

DISCUSSION

Patients undergoing surgery for femoral neck fracture with comorbid psychiatric illness are at increased risk for non-routine discharge. Schizophrenia is independently associated with an increased risk for post-operative complications. An awareness of these risks should optimize preoperative multidisciplinary patient care planning so as to maximize patient outcome and minimize resource utilization.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors.

METHODS

Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms "total knee arthroplasty" and "length of stay". Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (RevMan) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014).

RESULTS

A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference [MD] = 0.81; 95% confidence interval [CI] = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98).

CONCLUSION

This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative "fast-track" programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications.

LEVEL OF EVIDENCE

IV, systematic review, and meta-analysis of level III and IV evidence.

Preoperative Blood Management Strategy for Elective Hip and Knee Arthroplasty

To improve quality and outcomes, a preoperative anemia clinic (PAC) was established to screen, evaluate, and manage preoperative anemia. A retrospective review of primary and revision hip and knee arthroplasty patients from August 2013 to September 2017 was conducted. Patients at "high risk" for transfusion were referred to PAC for treatment with iron, erythropoietin, or both based on anemia type. Preoperative anemia clinic referred patients were compared with a 1:3 historic propensity-matched control set of patients to help determine impact of PAC. Forty PAC patients were compared with 120 control patients. Among PAC patients, 26 (63.41%) received iron only, 3 (7.32%) received erythropoietin (EPO) only, and 12 (29.27%) received both. Preoperative hemoglobin significantly increased in the treatment group (median [interquartile range] 10.9 g/dl [10.3-11.2] vs. 12.0 g/dl [11.2-12.7]; p < .001). Four PAC patients (10.00%) received red blood cell transfusions compared with 29 (24.17%) from matched controls (p = .055). In addition, the PAC cohort had higher postoperative nadir hemoglobin levels (mean [SD] 9.7 g/dl [1.31] vs. 8.7 g/dl [1.25]; p < .001). High-risk patients appropriately treated with iron and/or EPO before surgery demonstrate a significant increase in preoperative hemoglobin, trend toward decrease perioperative transfusion, and increased hemoglobin levels postoperatively compared with matched controls.

Blood Transfusion During Total Ankle Arthroplasty Is Associated With Increased In-Hospital Complications and Costs

INTRODUCTION

Total ankle arthroplasty (TAA) is an increasingly used, effective treatment for end-stage ankle arthritis. Although numerous studies have associated blood transfusion with complications following hip and knee arthroplasty, its effects following TAA are largely unknown. This study uses data from a large, nationally representative database to estimate the association between blood transfusion and inpatient complications and hospital costs following TAA.

METHODS

Using the Nationwide Inpatient Sample (NIS) database from 2004 to 2014, 25 412 patients who underwent TAA were identified, with 286 (1.1%) receiving a blood transfusion. Univariate analysis assessed patient and hospital factors associated with blood transfusion following TAA.

RESULTS

Patients requiring blood transfusion were more likely to be female, African American, Medicare recipients, and treated in nonteaching hospitals. Average length of stay for patients following transfusion was 3.0 days longer, while average inpatient cost was increased by approximately 50%. Patients who received blood transfusion were significantly more likely to suffer from congestive heart failure, peripheral vascular disease, hypothyroidism, coagulation disorder, or anemia. Acute renal failure was significantly more common among patients receiving blood transfusion ( P < .001).

CONCLUSION

Blood transfusions following TAA are infrequent and are associated with multiple medical comorbidities, increased complications, longer hospital stays, and increased overall cost.

LEVELS OF EVIDENCE

Level III: Retrospective, comparative study.

[Research status of the enhanced recovery after surgery in the geriatric hip fractures]

Objective

To summarize the latest developments in the enhanced recovery after surgery (ERAS) in the geriatric hip fractures and its perioperative therapy management.

Methods

The recent original literature on the ERAS in the geriatric hip fractures were extensively reviewed, illustrating the concepts and properties of the ERAS in the geriatric hip fractures.

Results

It has been considered to be associated with the decreased postoperative morbidity, reduced hospital length of stay, and cost savings to implement ERAS protocols, including multimodal analgesia, inflammation control, intravenous fluid therapy, early mobilization, psychological counseling, and so on, in the perioperative (emergency, preoperative, intraoperative, postoperative) management of the geriatric hip fractures. The application of ERAS in the geriatric hip fractures guarantees the health benefits of patients and saves medical expenses, which also provides basis and guidance for the further development and improvement of the entire process perioperative management in the geriatric hip fractures.

Conclusion

Significant progress has been made in the application of ERAS in the geriatric hip fractures. ERAS protocols should be a priority for perioperative therapy management in the geriatric hip fractures.

Decline in allogeneic blood transfusion usage in total hip arthroplasty patients: National Inpatient Sample 2009 to 2013

INTRODUCTION

Although total hip arthroplasty (THA) is an effective treatment for end-stage arthritis, it is also associated with substantial blood loss that may require allogeneic blood transfusion. However, these transfusions may increase the risk of certain complications. The purpose of our study is to evaluate: (i) the incidence/trends of allogeneic blood transfusion; (ii) the associated risk factors and adverse events; and (iii) the discharge disposition, length of stay (LOS), and costs for these patients between 2009 and 2013.

METHODS

The National Inpatient Sample database was used to identify 1,542,366 primary THAs performed between 2009 and 2013. Patients were stratified based on demographics, economic data, hospital characteristics, comorbidities, and whether or not allogeneic transfusion was received. Logistic regression was performed to evaluate the risk factors for transfusion and postoperative complications.

RESULTS

From 2009 to 2013, allogeneic transfusions were used in 16.9% of primary THAs, with a declining annual incidence. Except for obesity, all comorbidities were associated with increased likelihood of receiving a transfusion. Allogeneic transfusion patients were more likely to experience surgical site infections or pulmonary complications (p<0.001 for all). These patients were more likely to be discharged to a short-term care facility (p<0.001). Additionally, they had a greater mean LOS (p<0.001) and higher median hospital costs and charges when compared to their non-transfused counterparts.

CONCLUSIONS

While the observed decline in allogeneic transfusion usage is encouraging, further efforts should focus on preoperative patient optimisation. Given the projected increase in demand for primary THAs, orthopaedic surgeons must be familiar with safe and effective blood conservation protocols.

Total Knee Arthroplasty: Does Day of Surgery Matter?

Introduction

There has been an influx of research studies aimed at identifying all factors that contribute to minimizing cost and maximizing postoperative care after total knee arthroplasty (TKA). Length of stay (LOS) has been defined as a significant factor that contributes to increased burden. We aimed at looking whether day of surgery has any significant effect on the LOS and postoperative complications following total knee arthroplasty (TKA).

Materials and methods

Retrospective cohort study done at the Aga Khan University Hospital, Pakistan, from January 2007 to December 2015. A total of 611 patients who underwent a unilateral or bilateral total knee arthroplasty (TKA) were included in study: 269 (44.0%) patients underwent unilateral TKA and 342 (56.0%) underwent a bilateral TKA.

Results

Kruskal-Wallis test and post hoc pairwise comparisons showed that unilateral TKAs performed on Tuesday, Saturday, and Sunday resulted in a lower median LOS (P < .05). No significant association was seen in bilateral TKA group. Day of surgery was not associated with postoperative complications.

Conclusions

Unilateral TKAs performed earlier during the week and later on the weekend are associated with a significantly lower LOS. It is highly probable that patch ancillary services during the latter part of the week and a higher workload for the staff are important reasons for this phenomenon.

Patients at Risk: Large Opioid Prescriptions After Total Knee Arthroplasty

BACKGROUND

Opioids are an effective, and often necessary, treatment of postoperative pain after total knee arthroplasty (TKA). However, it is often difficult to know how much medication patients will need after discharge. The purpose of this study was to determine if patients discharged with greater quantities of opioids after TKA are more likely to request refills.

METHODS

This is a retrospective review of 105 primary TKAs performed with at least 1 year of follow-up. Exclusion criteria included bilateral TKA, preoperative opioid use, or reoperation within the first 3 months. Data collected included opioid refills, Knee Society Score, and total and daily morphine equivalent dose (MED) prescribed.

RESULTS

Patients were most commonly discharged on oxycodone (90%), hydromorphone (5%), and hydrocodone/acetaminophen (1%). The average total prescribed MED was 1405 ± 616 mg (range, 273-3250 mg). Patients requiring refills did not differ in the total prescribed MED (1521 ± 624 vs 1349 ± 609 mg; P = .1), daily prescribed MED (153 ± 10 vs 155 ± 7 mg; P = .8), or preoperative Knee Society Score (63 ± 16 vs 60 ± 13; P = .3). Average follow-up time was 2.4 ± 0.5 years.

CONCLUSION

The quantity of opioids prescribed after TKA varied widely, ranging from a total MED of 273-3250 mg. The refill rate did not differ between large prescriptions (≥1400 mg) and smaller prescriptions. Excessive opioid prescriptions should be avoided as they did not decrease the number of refills and pose the risk of divergence and subsequent abuse.

Multivariable analysis of factors affecting length of stay and hospital charges after single-level corpectomy

Anterior cervical corpectomy and fusion (ACCF) is commonly employed for treating myelopathy, deformity, and a variety of other cervical pathologies. Limited data are available on factors associated with longer hospitalization and higher hospital charges following ACCF. The purpose of this study was to evaluate the pre-, intra-, and postoperative variables that are associated with length of hospital stay and hospital charges for patients undergoing single-level anterior cervical corpectomy and fusion in a retrospective case series. We retrospectively identified from a clinical database 69 patients who underwent single-level ACCF at a single institution from 2010 through 2014. Demographic variables, clinical information, and intraoperative data were analyzed with respect to length of hospitalization and hospital charges. T-test and Chi-squared testing as well as univariate and multivariable analysis were performed with p<0.05 considered significant. On multivariable analysis, polytrauma, postoperative complications, lower postoperative hematocrit, and two-staged procedures were significantly associated with longer lengths of stay. Length of stay, postoperative complications, and two-staged procedures were significantly associated with higher hospital charges. Patients undergoing a two-staged procedure and those having postoperative complications experience a longer postoperative length of stay and incur higher hospital charges. Avoidance of postoperative anemia may help to reduce length of stay following ACCF.

Association between preoperative anaemia with length of hospital stay among patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study

OBJECTIVES

Studies in western healthcare settings suggest that preoperative anaemia is associated with poor outcomes after elective orthopaedic surgery. We investigated the prevalence of preoperative anaemia among patients with primary unilateral total knee arthroplasty (TKA) in Singapore and its association with length of hospital stay (LOS), perioperative blood transfusion and hospital readmission rates.

METHODS

Retrospective cohort study performed in a tertiary academic medical centre in Singapore, involving patients who underwent primary unilateral TKA between January 2013 and June 2014. Demographics, comorbidities, preoperative haemoglobin (Hb) level, LOS and 30-day readmission data were collected. Anaemia was classified according to WHO definition. Prolonged LOS was defined as more than 6 days, which corresponds to >75th centile LOS of the data.

RESULTS

We analysed 2394 patients. The prevalence of anaemia was 23.7%. 403 patients (16.8%) had mild anaemia and 164 patients (6.8%) had moderate to severe anaemia. Overall mean LOS was 5.4±4.8 days. Based on multivariate logistic regression, preoperative anaemia significantly increased LOS (mild anaemia, adjusted OR (aOR) 1.71, p<0.001; moderate/severe anaemia, aOR 2.29, p<0.001). Similar effects were seen when preoperative anaemia was defined by Hb level below 13 g/dL, regardless of gender. Transfusion proportionately increased prolonged LOS (1 unit: aOR 2.12, p=0.006; 2 or more units: aOR 6.71, p<0.001). Repeat operation during hospital stay, previous cerebrovascular accidents, general anaesthesia and age >70 years were associated with prolonged LOS. Our 30-day related readmission rate was 1.7% (42) cases.

CONCLUSION

Anaemia is common among patients undergoing elective TKA in Singapore and is independently associated with prolonged LOS and increased perioperative blood transfusion. We suggest measures to correct anaemia prior to surgery, including the use of non-gender-based Hb cut-off for establishing diagnosis.

Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty

BACKGROUND

Hospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). We sought to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA.

METHODS

Prospective data were reviewed from 716 consecutive, primary TKA procedures performed by two arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans RAND-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to other adjusters. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively.

RESULTS

After adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI <25) overweight (25-29.9) was associated with longer LOS by 0.32days (P=0.038), class-I obesity (30-34.9) by 0.33days (P=0.024), class-II obesity (35-39.9) by 0.67days (P=0.012) and class-III obesity (>40) by 1.15days (P<0.001). Class-III obesity was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20-29 was associated with a LOS increase of 0.40days (P=0.014) and PCS<20 with a LOS increase of 0.64days (P=0.031).

CONCLUSION

Patient BMI has a dose-response effect in increasing LOS. Poor PCS was associated similarly with increased LOS. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA.

Topical Tranexamic Acid is Equivalent to Targeted Preoperative Autologous Blood Donation in Total Hip Arthroplasty

BACKGROUND

Topical tranexamic acid (TXA) was introduced to replace the previous targeted preoperative autologous blood donation (PABD) program. This study aims to analyze the efficacy of topical TXA compared with targeted PABD in anemic patients undergoing primary total hip arthroplasty (THA).

METHODS

Two thousand two hundred fifty-one patients underwent primary THA between 2009 and 2013 using targeted autologous blood donation for 280 anemic patients (12%; Hb <12.5 g/dL). One thousand nine hundred seventy-one nonanemic patients (88%; ≥12.5 Hb/dL) received no blood management intervention. Starting in 2014, 505 consecutive patients were operated using 3 grams of topical TXA and abandoning PABD. Ninety-one patients (18%) were anemic and 414 (82%) nonanemic.

RESULTS

The utilization of topical TXA in anemic patients resulted in higher hemoglobin levels on the first postoperative day (P = .014), but not on the second postoperative day (P = .198) compared with PABD. There was no difference in allogeneic transfusion rates between both groups: 12% vs 13% (P = .848). In the nonanemic group, TXA significantly increased hemoglobin levels on the first postoperative day (P = .001) as well as on the second postoperative day (P < .001), and resulted in a reduction in allogeneic transfusion rates from 8% to 1%.

CONCLUSION

The present study suggests that topical TXA is equivalent to PABD in anemic patients and reduces transfusion rates and increases Hb-levels in nonanemic patients.

Length of stay and short-term functional outcomes after total knee arthroplasty: Can we predict them?

BACKGROUND

To identify variables influencing length of stay (LOS) and short-term functional outcome in patients undergoing total knee arthroplasty (TKA). A secondary aim was to verify the effect of the same variables on blood management and the rate of postoperative infection.

METHOD

We retrospectively reviewed 353 patients, 258 females and 85 males, who underwent primary TKA in a single specialist orthopaedic centre. Anamnestic and anthropometric data and the Modified Barthel Index Score (MBI) at admission were recorded, and entered as covariates in four longitudinal regression models, separately carried out for female and male groups. The regression outcomes were LOS, MBI change, rate of infection and blood transfusion. Statistical significance was set at p<0.05.

RESULTS

Mean LOS was 15.93±4.97days for females and 13.41±3.63days for males. Mean MBI improvement was statistically significant in both groups. 46.3% females and 29.4% males needed at least one blood transfusion, while infections complicated the hospitalization in 14.6% and 4.7% cases respectively. Among females, older age was predictive for a longer LOS and poorer post-operative MBI improvement. Lower MBI at admission was related to a longer LOS and to a higher risk of post-surgical infections in the female group, but to a better improvement of functional outcome in both groups. A higher rate of blood transfusion postoperatively was associated to lower pre-surgical haemoglobin levels and, for females, to older age and lower BMI.

CONCLUSION

An accurate characterization of TKA candidates might help in reducing LOS and in achieving a better early functional outcome.

Impact of preoperative antithrombotic therapy on blood management after implantation of primary total knee arthroplasty

Red blood cell concentrates (RCC) substitution after total knee arthroplasty (TKA) is correlated with multifold of complications and an independent predictor for higher postoperative mortality. TKA is mainly performed in elderly patients with pre-existing polymorbidity, often requiring permanent preoperative antithrombotic therapy (PAT). The aim of this retrospective analysis was to investigate the impact of demand for PAT on inpatient blood management in patients undergoing TKA. In this study 200 patients were retrospectively evaluated after TKA for differences between PAT and non-PAT regarding demographic parameters, preoperative ASA score > 2, duration of operation, pre-, and intraoperative hemoglobin level, and postoperative parameters including amount of wound drainage, RCC requirement, and inpatient time. In a multivariate logistic regression analysis the independent influences of PAT, demographic parameters, ASA score > 2, and duration of the operation on RCC demand following TKA were analyzed. Patients with PAT were significantly older, more often had an ASA > 2 at surgery, needed a higher number of RCCs units and more frequently and had lower perioperative hemoglobin levels. Multivariate logistic regression revealed PAT was an independent predictor for RCC requirement. PAT patients are more likely to require RCC following TKA and should be accurately monitored with respect to postoperative blood loss.

Noninvasive Hemoglobin Monitoring: A Rapid, Reliable, and Cost-Effective Method Following Total Joint Replacement

BACKGROUND

Noninvasive hemoglobin (nHgb) monitoring was initially introduced in the intensive care setting as a means of rapidly assessing Hgb values without performing a blood draw. We conducted a prospective analysis to compare reliability, cost, and patient preference between nHgb monitoring and invasive Hgb (iHgb) monitoring performed via a traditional blood draw.

METHODS

We enrolled 100 consecutive patients undergoing primary or revision total hip or total knee arthroplasty. On postoperative day 1, nHgb and iHgb values were obtained within thirty minutes of one another. iHgb and nHgb values, cost, patient satisfaction, and the duration of time required to obtain each reading were recorded. The concordance correlation coefficient (CCC) was utilized to evaluate the agreement of the two Hgb measurement methods. Paired t tests and Wilcoxon signed-rank tests were utilized to compare mean Hgb values, time, and pain for all readings.

RESULTS

The mean Hgb values did not differ significantly between the two measurement methods: the mean iHgb value (and standard deviation) was 11.3 ± 1.4 g/dL (range, 8.2 to 14.3 g/dL), and the mean nHgb value was 11.5 ± 1.8 g/dL (range, 7.0 to 16.0 g/dL) (p = 0.11). The CCC between the two Hgb methods was 0.69. One hundred percent of the patients with an nHgb value of ≥ 10.5 g/dL had an iHgb value of >8.0 g/dL. The mean time to obtain an Hgb value was 0.9 minute for the nHgb method and 51.1 minutes for the iHgb method (p < 0.001). At our institution, the cost of iHgb monitoring is approximately $28 per blood draw compared with $2 for each nHgb measurement, resulting in a savings of $26 per Hgb assessment when the noninvasive method is used.

CONCLUSIONS

Noninvasive Hgb monitoring was found to be more efficient, less expensive, and preferred by patients compared with iHgb monitoring. Providers could consider screening total joint arthroplasty patients with nHgb monitoring and only order iHgb measurement if the nHgb value is <10.5 g/dL. If this protocol had been applied to the first blood draw in our 100 patients, approximately $2000 would have been saved. Extrapolated to the U.S. total joint arthroplasty practice, approximately $20 million could be saved annually.

The Reinfusion of Autogenous Shed Blood After Unilateral Total Knee Arthroplasty Using the Perioperative Autologous Transfusion System OrthoPAT

This study aims to explore the use of postoperative autogenous shed blood reinfusion using Orthopedic Perioperative Autotransfusion System (OrthoPAT) system in treating patients undergoing unilateral total knee arthroplasty (TKA). Fifty patients undergoing unilateral TKA were enrolled as the experimental group A and were treated with reinfusion of autologous shed blood within 6 hours after unilateral TKA using OrthoPAT. Accordingly, 50 patients undergoing unilateral TKA were selected as the experimental group B and were treated with allogeneic blood transfusion. Different indexes were observed at different times. Patients in both groups had relatively stable hemodynamics, and there was no postoperative coagulopathy. Prothrombin time, thrombin time, and activated partial thromboplastin time were lower, and fibrinogen was higher in group A than that in group B 24 hours after surgery (all P < 0.05). White blood cell, red blood cell, hemoglobin, hematocrit (Hct), and platelet count levels in group A were lower than those in group B 12 hours after surgery (all P < 0.05). The postoperative complications of the 2 groups have significant difference (P < 0.05). Postoperative autogenous shed blood reinfusion using OrthoPAT system in the treatment of patients undergoing unilateral TKA may improve the coagulation function of patients and reduce the rejection caused by standard allogeneic blood transfusion.

Comorbidities in patients undergoing total knee arthroplasty: do they influence hospital costs and length of stay?

BACKGROUND

Increasing national expenditures and use associated with TKA have resulted in pressure to reduce costs through various reimbursement cuts. However, within the arthroplasty literature, few studies have examined the association of medical comorbidities on resource use and length of stay after joint arthroplasty.

QUESTIONS/PURPOSES

The purpose of this study was to examine the association between individual patient characteristics (including demographic factors and medical comorbidities) on resource allocation and length of stay (LOS) after TKA.

METHODS

We queried the 2009 Nationwide Inpatient Sample dataset for International Classification of Diseases, 9(th) Revision code, 81.54, for TKAs. An initial 621,029-patient cohort was narrowed to 516,745 after inclusion of elective TKAs on patients aged between 40 and 95 years. Using generalized linear models, we estimated the effect of comorbidities on resource use (using cost-to-charge conversions to estimate hospital costs) and the LOS controlling for patient and hospital characteristics. Across the 2009 national cohort with TKAs, 12.7% had no comorbidities, whereas 32.6% had three or more. The most common conditions included hypertension (67.8%), diabetes (20.0%), and obesity (19.8%). Mean hospital costs were USD 14,491 (95% confidence interval [CI], 14,455-14,525) and mean hospital LOS was 3.3 days (95% CI, 3.29-3.31) in this data set.

RESULTS

Patients with multiple comorbidities were associated with increased resource use and LOS. Higher marginal costs and LOS were associated with patients who had an inpatient death (USD +8017 [95% CI, 8006-8028], +2.3 [CI, 2.15-2.44] days over baseline), patients with recent weight loss (USD +4587 [95% CI, 4581-4593], +1.5 [CI, 1.45-1.61) days], minority race (USD +1037 [95% CI, 1035-1038], +0.3 [CI, 0.28-0.33] days), pulmonary-circulatory disorders (USD +3218 [95% CI, 3214-3221], +1.3 [CI, 1.25-1.34] days), and electrolyte disturbances (USD +1313 [95% CI, 1312-1314], +0.6 [CI, 0.57-0.60] days). All p values were < 0.001.

CONCLUSION

Multiple patient comorbidities were associated with additive resource use and LOS after TKA. Current reimbursement may not adequately account for these patient characteristics. To avoid potential loss of access to care for sicker patients, payment needs to be adjusted to reflect actual resource use.

LEVEL OF EVIDENCE

Level IV, economic and decision analysis. See the Instructions for Authors for a complete description of levels of evidence.