Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty

Sleep Apnea is Not an Obstacle for Outpatient Hip and Knee Arthroplasty

BACKGROUND

Up to 25% of patients requiring hip or knee arthroplasty have sleep apnea (SA), and these patients have historically been excluded from outpatient programs. The objectives of this study were to evaluate same-day discharge failure as well as 30-day complications, readmissions, and unexpected visits.

METHODS

A retrospective case-control study comparing patients who have and do not have SA matched for age, sex and arthroplasty type (total hip arthroplasty, total knee arthroplasty, unicompartimental knee arthroplasty) who underwent primary outpatient surgery between February 2019 and December 2022 in 2 academic hospitals was conducted. Cases with mild SA, moderate SA with a body mass index (BMI) <35, and SA of all severity treated by continuous positive airway pressure machines were eligible. There were 156 patients included (78 cases). Complications were assessed according to the Clavien-Dindo Classification and the Comprehensive Complication Index. Continuous variables were evaluated by Student's T or Mann-Whitney tests, while categorical data were analyzed by Chi-square or Fisher tests. Univariate analyses were performed to determine discharge failure risk factors.

RESULTS

There were 6 cases (7.7%) and 5 controls (6.4%) who failed to be discharged on surgery day (P = .754), with postoperative hypoxemia (6, [3.8%]) and apnea periods (3, [1.9%]) being the most common causes. Higher BMI (odds ratio = 1.19, P = .013) and general anesthesia (odds ratio = 11.97, P = .004) were found to be risk factors for discharge failure. No difference was observed on 30-day readmissions (P = .497), unexpected visits (P = 1.000), and complications on the Clavien-Dindo Classification (P > .269) and Comprehensive Complication Index (P > .334) scales.

CONCLUSIONS

Selected patients who have SA can safely undergo outpatient hip or knee arthroplasty. Higher BMI and general anesthesia increased the odds of same-day discharge failure.

LEVEL OF EVIDENCE

Level III, Case-control Study.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Postoperative outcomes and anesthesia type in total knee arthroplasty in patients with obstructive sleep apnea

Aim: We investigated the relationship between obstructive sleep apnea (OSA), 30/90-day readmission rates and perioperative complications (postoperative cardiovascular, gastrointestinal, infectious or intraoperative complications) in patients undergoing total knee arthroplasty. Materials & methods: We analyzed records of patients who underwent total knee arthroplasty using State Inpatient Databases. Demographics, comorbidities, 30/90-day readmission rates and complications were compared by OSA status. For NY, USA we analyzed outcomes by anesthetic type (regional vs general). Results: OSA patients were mostly male, had more comorbidities and had increased 30/90-day readmission rates. There were no differences in complications. In NY, there were no differences in outcomes by anesthetic type. Conclusion: OSA was associated with increased 30/90-day readmission rates. Within NY, anesthetic type was not associated with any outcomes.

The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty

Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA.

Improvement of sleep quality 6 months after total knee arthroplasty: a systematic review and meta-analysis

Background

Total knee arthroplasty (TKA) is an accepted, effective treatment to restore function, relieve pain, and improve the quality of life in patients with advanced osteoarthritis. One complication of this major surgery is impaired sleep quality. This study examines the quality of sleep in patients undergoing TKA before and after their operation.

Methods

All relevant records were obtained using a systematic search in three online databases: PubMed, Scopus, and Cochrane library. Out of the 177 records retrieved, only eight matched the inclusion criteria. Due to the lack of sufficient data, only four studies entered the meta-analysis. Values reported for sleep quality based on the Pittsburgh Sleep Quality Index (PSQI) were extracted from patient records before and after surgery. A random-effect model was used to analyze the data.

Results

The results of the meta-analysis show a significant difference in the improvement of sleep quality after surgery at two time points of 4–6 weeks after surgery from the preoperative baseline (SMD − 0.16; 95% CI − 1.05 to 0.74; P = 0.0) and 3–6 months after surgery from the preoperative baseline (SMD − 0.92; 95% CI − 1.61 to − 0.24; P = 0.0).

Conclusions

The results show that TKA generally improves the patients’ sleep quality. Although some studies reported disrupted sleep quality in periods close to the surgery (especially in the early days after surgery), all studies have reported improved sleep quality in the late postoperative intervals.

Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review

The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients

BACKGROUND

This study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs).

METHODS

Between July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index.

RESULTS

Before surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3).

CONCLUSION

Improvement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.

Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases

STUDY OBJECTIVES

To investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type.

DESIGN

Retrospective analysis.

SETTING

Operating room.

PATIENTS

349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%).

INTERVENTIONS

No intervention.

MEASUREMENTS

The effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year.

MAIN RESULTS

The OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31-1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased.

CONCLUSIONS

The OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.

Pulmonary complications in trauma patients with obstructive sleep apnea undergoing pelvic or lower limb operation

Background

Obstructive sleep apnea (OSA) is increasingly prevalent in the range of 2% to 24% in the US population. OSA is a well-described predictor of pulmonary complications after elective operation. Yet, data are lacking on its effect after operations for trauma. We hypothesized that OSA is an independent predictor of pulmonary complications in patients undergoing operations for traumatic pelvic/lower limb injuries (PLLI).

Methods

Nationwide Inpatient Sample (2009–2013) was queried for International Classification of Diseases, Ninth Revision, Clinical Modification codes for PLLI requiring operation. Elective admissions and those with concurrent traumatic brain injury with moderate to prolonged loss of consciousness were excluded. Outcome measures were pulmonary complications including ventilatory support, ventilator-associated pneumonia, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), and respiratory failure. Multivariable logistic regression analysis was used, adjusting for OSA, age, sex, race/ethnicity, and specific comorbidities (obesity, chronic lung disease, and pulmonary circulatory disease). P<0.01 was considered statistically significant.

Results

Among the 337 333 patients undergoing PLLI operation 3.0% had diagnosed OSA. Patients with OSA had more comorbidities and were more frequently discharged to facilities. Median length of stay was longer in the OSA group (5 vs 4 days, p<0.001). Pulmonary complications were more frequent in those with OSA. Multivariable logistic regression showed that OSA was an independent predictor of ventilatory support (adjusted odds ratio (aOR), 1.37; 95% CI,1.24 to 1.51), PE (aOR 1.40; 95% CI, 1.15 to 1.70), ARDS (aOR 1.36; 95% CI,1.23 to 1.52), and respiratory failure (aOR 1.90; 95% CI, 1.74 to 2.06).

Conclusion

OSA is an independent and underappreciated predictor of pulmonary complications in those undergoing emergency surgery for PLLI. More aggressive screening and identification of OSA in trauma patients undergoing operation are necessary to provide closer perioperative monitoring and interventions to reduce pulmonary complications and improve outcomes.

Level of evidence

Prognostic Level IV.

A sleep disturbance after total knee arthroplasty

Background:

Knee osteoarthritis (OA) is common arthritis in elderly. Total knee arthroplasty; (TKA) is effective to restore mobility and improve quality of life in patients with OA. One of TKA complications is sleep disturbance.

Objective:

Aim was to evaluate sleep disturbance after TKA despite differences in postoperative pain managements.

Methods:

Prospective cohort study was performed on 67 patients who underwent primary TKA by different surgeons during May to March 2019. Samples were collected randomly from different hospitals in Sulaimani, Kurdistan, Iraq. Sleep pattern was assessed by Pittsburgh Sleep Quality Index (PSQI) and pain was assessed by visual analogue scale (VAS) for three months postoperatively.

Results:

Mean ± standard deviation (SD) age (year) and body mass index (BMI; kg/m²) of participants were 64.2 ± 7.5 (range: 40–82) and 27.3 ± 3.7 (range: 21.3–41.6), respectively. About 83.6% were females with male to female ratio of (0.2:1). There were statistically insignificant associations of age, gender, BMI, and history of diabetes mellitus with PSQI. Degree of pain was gradually decreasing during follow-up, but sleep was better at beginning followed by peaked disturbance after one month, then it started to improve gradually at end of follow-up.

Conclusions:

Sleep disturbance assessment needs multimodal approaches in order to improve it and satisfy patients.

Review article: Patient characteristics that act as risk factors for intraoperative complications in hip, knee, and shoulder arthroplasties

The number of annual THA's, TKA's, and TSA's is set to increase significantly by the year 2030, making it imperative to understand the risks for negative outcomes in these procedures. While research has studied the patient risk factors for perioperative and postoperative complications, there has been relatively little research for intraoperative complications. After a thorough literature review, the most supported finding was that patients with a BMI >30 had significantly more intraoperative blood loss than those with a BMI <30. All other relationships between patient risk factors and intraoperative complications of interest were inadequately studied.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Obstructive Sleep Apnea and Arthroscopic Rotator Cuff Repair-Are Complication Rates Really Increased?

BACKGROUND

A few investigations exist which evaluate the influence of obstructive sleep apnea (OSA) on complications after arthroscopic rotator cuff repair.

METHODS

A database was queried for patients undergoing rotator cuff repair with and without OSA and further subdivided into those with and without a billing code for a continuous positive airway pressure (CPAP) device. Thirty-day and 6-month adverse events were assessed.

RESULTS

After regression analysis, patients with OSA had markedly increased emergency department visits and hospital admission (P < 0.05). This risk was mitigated by CPAP orders compared with control subjects. Patients without CPAP use had markedly increased risks of emergency department visits, hospital admission, and respiratory complications compared with control subjects (P < 0.05).

CONCLUSIONS

Patients with OSA have higher risks of emergency department visits and hospital admissions postoperatively; however, a CPAP order appears to mitigate this risk. The independent risk imparted by OSA for the studied complications was markedly lower than other comorbidities.

Risk stratification in primary total joint arthroplasty: the current state of knowledge

Background

As we transition to value-based care delivery models, risk stratification in total joint arthroplasty is more important than ever. The purpose of this study was to identify patients who would likely require higher level of care and may not be suitable for inclusion in bundled payment models.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent primary total joint arthroplasty between 2011 and 2012. Five types of adverse events were assessed: medical complications, surgical complications, readmission, reoperation, and mortality. Univariate and multivariate logistic regression analyses were performed using a large number of demographic and morbidity variables.

Results

A total of 14,185 patients were identified. The 30-day medical complication, surgical complication, readmission, reoperation, and mortality rates were 2.0%, 3.2%, 4.0%, 1.5%, and 0.2%, respectively. Among the different variables assessed, only the American Society of Anesthesiologists (ASA) physical classification system was a significant risk factor for most outcomes assessed. Peripheral vascular disease was the most significant risk factor for medical complications and reoperation (odds ratio, 2.73 and 3.23, respectively). Bleeding disorders were the most significant risk factor for readmission and mortality (odds ratio, 2.03 and 5.86, respectively).

Conclusions

ASA score is a more reliable risk stratification tool than Charlson Comorbidity Index, but it is not sufficient by itself. Patients with higher ASA scores combined with peripheral vascular disease and/or bleeding disorders are at especially high risk of developing postsurgical adverse events and may not be suitable for inclusion in bundled payment models. These data can be used to develop better risk stratification models that are critically needed.

Perioperative impact of sleep apnea in a high-volume specialty practice with a strong focus on regional anesthesia: a database analysis

Background and objectives

Obstructive sleep apnea (OSA) is a risk factor for adverse postoperative outcome and perioperative professional societies recommend the use of regional anesthesia to minimize perioperative detriment. We studied the impact of OSA on postoperative complications in a high-volume orthopedic surgery practice, with a strong focus on regional anesthesia.

Methods

After Institutional Review Board approval, 41 766 cases of primary total hip and knee arthroplasties (THAs/TKAs) from 2005 to 2014 were extracted from institutional data of the Hospital for Special Surgery (approximately 5000 THAs and 5000 TKAs annually, of which around 90% under neuraxial anesthesia).

The main effect was OSA (identified by the International Classification of Diseases, ninth revision codes); outcomes of interest were cardiac, pulmonary, gastrointestinal, renal/genitourinary, thromboembolic complications, delirium, and prolonged length of stay (LOS). Multivariable logistic regression models provided ORs, corresponding 95% CIs, and p values.

Results

Overall, OSA was seen in 6.3% (n=1332) of patients with THA and 9.1% (n=1896) of patients with TKA. After adjustment for relevant covariates, OSA was significantly associated with 87% (OR 1.87, 95% CI 1.51 to 2.30), 52% (OR 1.52, 95% CI 1.13 to 2.04), and 44% (OR 1.44,95% CI 1.31 to 1.57) increased odds for pulmonary gastrointestinal complications, and prolonged LOS, respectively. The odds for other outcomes remained unaltered by OSA diagnosis.

Conclusion

We showed that, even in a setting with almost universal regional anesthesia use, OSA was associated with increased odds for prolonged LOS, and pulmonary and gastrointestinal complications. This puts forward the question of how effective regional anesthesia is in mitigating postoperative complications in patients with OSA.

Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

BACKGROUND

Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs.

METHODS

This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015).

RESULTS

The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m² or 35-40 kg/m² with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93).

CONCLUSION

In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.