Total hip arthroplasty in an outpatient setting in 27 selected patients

Background and purpose — As a result of introduction of a fast-track program, length of hospital stay after total hip arthroplasty (THA) decreased in our hospital. We therefore wondered whether THA in an outpatient setting would be feasible. We report our experience with THA in an outpatient setting.

Patients and methods — In this prospective cohort study, we included 27 patients who were selected to receive primary THA in an outpatient setting between April and July 2014. Different patient-reported outcome measures (PROMs) were recorded preoperatively and at 6 weeks and 3 months postoperatively. Furthermore, anchor questions on how patients functioned in daily living were scored at 6 weeks and 3 months postoperatively.

Results — 3 of the 27 patients did not go home on the day of surgery because of nausea and/or dizziness. The remaining 24 patients all went home on the day of surgery. PROMs improved substantially in these patients. Moreover, anchor questions on how patients functioned in their daily living indicated that the patients were satisfied with the postoperative results. 1 re-admission occurred at 11 days after surgery because of seroma formation. There were no other complications or reoperations.

Interpretation — At our hospital, with a fast-track protocol, outpatient THA was found to be feasible in selected patients with satisfying results up to 3 months postoperatively, without any outpatient procedure-specific complications or re-admissions.     

24 hours stay after hip replacement

Background and purpose — The length of stay after total hip arthroplasty has been reduced to 2–4 days after implementing fast-track surgery. We investigated whether a new time-based patient-centered primary direct anterior approach (DAA) total hip arthroplasty (THA) treatment protocol in a specialized clinic, with a planned length of stay of about 24?hours, could be achieved in all patients or only in a selected group of patients.

Patients and methods — We analyzed prospectively collected data in a cohort of 378 consecutive patients who underwent a primary direct anterior THA as a patient-centered time-based procedure between March 1, 2012 and December 31, 2015. Patients with complicated medical comorbidity and those over the age of 85 were excluded from the study. The average length of stay was recorded and all complications, re-admissions, and reoperations were registered and analyzed. The primary outcome measures were length of stay and complication rate, at discharge and 90 days postoperatively.

Results — The average length of stay for all patients was 26?hours. All patients were discharged from the clinic on the day after the operation and were able to continue their recovery at home or in a rehabilitation facility. The overall complication rate within 3 months of surgery was 6%. The 3-month re-admission rate and the 3-month reoperation rate were both 2%.

Interpretation — Performing a time-based, patient-centered fast-track program for DAA total hip arthroplasty can result in a standardized length of stay of about 24?hours and a high level of patient satisfaction with few complications, re-admissions, and reoperations.     

Elbow-Wrist-Thumb Immobilisation in the Treatment of Fractures of the Carpal Scaphoid

Background and purpose Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA.

Patients and methods To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered.

Results Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients.

Interpretation Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.     

Databases for hip fracture audit

Background and purpose Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications.

Patients and methods We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications.

Results There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction

(0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8).

Interpretation This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.     

Enhanced Recovery after Implementation of Surgery Protocol in Living Kidney Donors: The ISMETT Experience

IntroductionLaparoscopic living donor nephrectomy (LLDN) has become the standard procedure for living kidney transplantation. Enhanced recovery after surgery (ERAS) is a multimodal perioperative management aimed at facilitating rapid patient recovery after major surgery by modifying the response to stress induced by exposure to surgery. This association can further reduce hospital stay, surgical stress, and perioperative morbidity of living kidney donors.Material and methodsIn this retrospective analysis conducted at our institute, we compared the first 21 patients who underwent LLDN enrolled with the ERAS protocol with 55 patients who underwent LLDN with the fast-track protocol in the 5 years prior to ERAS protocol implementation.ResultsWe evaluated 76 consecutive patients. After ERAS protocol implementation, elderly living donors had a shorter hospital stay and a faster return to normal life compared with the same age group of patients in the previous period. There were no major differences in median postoperative hospital stay and no meaningful differences in the percentage of complications after surgery and hospital readmissions.ConclusionsThe introduction of the ERAS protocol for patients undergoing LLDN compared with the traditional protocol led to a reduction in postoperative hospitalization in elder donors, without determining a raise in the number of hospital complications and readmissions.     

Análisis del tratamiento del prolapso de órganos pélvicos mediante colposacropexia mínimamente invasiva con 24 horas de ingreso

ObjectivesThe objective of this study is to analyze the impact (in terms of safety and saving of hospital costs) of the implementation of a new protocol for the correction of pelvic organ prolapse (POP) by minimally invasive sacrocolpopexy (MISC) with 24-hour hospital stay.Material and methodsProspective observational study of the first 78 MISC procedures performed consecutively. 46 procedures (59%) were performed with 24-hour hospital stay, and 32 (41%) required more than 24 hours. The postoperative complications were determined for each group: visits to the Emergency Department, reoperations, and the average cost per procedure regarding hospital stay and ER visits. The cost model was established according to the data of the Analytical Accounting System of the Jiménez Díaz Foundation Hospital and of the Official State Gazette of Madrid.ResultsThere were no differences regarding intraoperative or postoperative complications between both groups. The number of visits to the Emergency Department, reinterventions or hospital re-admissions was lower in the 24-hour hospital stay group, without reaching statistical significance. The implementation of the MISC protocol with 24-hour hospital stay represented a saving of 607.91€ per procedure in hospital costs.ConclusionsCorrection of the POP with MISC with a 24-hour hospital discharge policy was feasible and safe in at least 59% of the patients, with similar complications, visits to the Emergency Department or hospital readmission rates.     

Is there a difference in laparoscopic cholecystectomy performed in a teaching hospital or a general hospital in The Netherlands?

Introduction: Laparoscopic cholecystectomy may have a complicated course with severe complications such as bile duct injury. Studies in other countries than the Netherlands report ambivalent results regarding the influence of a residency program on patient safety, efficacy and financial consequences. This study aims to determine whether there is a difference between laparoscopic cholecystectomy performed in a teaching hospital or a non-teaching general hospital in Dutch clinics.

Materials and methods: A prospective cohort study was performed to examine the safety of laparoscopic cholecystectomies in a teaching hospital with a residency program and a general hospital without surgical residents. All consecutive cholecystectomies in these two hospitals between September 2014 and March 2015 were included. Patient characteristics, operative procedure, level of experience, operation time, per- and postoperative complications, mortality, length of hospital stay, re-admittance and conversions to laparotomy were analyzed.

Results: A total of 294 consecutive cholecystectomies were performed in both hospitals. Cholecystectomies performed in the teaching hospital took an average of 25?min longer to complete compared with a non-residency setting. Both the number of conversions and the number of re-admissions were not significantly different between both clinics. The residency program showed smaller peroperative liver lesions along with more postoperative complications, with most complications in patients that required a conversion.

Discussion: Current practice where residents perform supervised cholecystectomies should not be discouraged. We believe that is safe and lead to an acceptable increase in operation time.     

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

BackgroundEnhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.Materials en methodsThe effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.Results152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).ConclusionAn enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.     

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BackgroundDespite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.MethodsAn ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).ResultsWe included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5–9] vs 8 [7–9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol.ConclusionsImplementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.     

Labelling as reference Centre of GRACE (Groupe francophone de Réhabilitation Améliorée après ChirurgiE) for colorectal surgery: its impact on the implementation of enhanced recovery programme at the University Hospital of Liège

Background: Enhanced recovery programme (ERP) has been used in our hospital since 2005 for selected colorectal surgeries. Since October 2015, after labelling as GRACE reference centre, we included all patients scheduled for elective colorectal surgery in this programme. We assessed the impact of our labelling on the implementation of ERP.

Methods: Results of our first 100 patients entered in the GRACE database were analyzed: length of stay, complications, readmission, adherence to the protocol. These results are compared to those of the last 100 patients undergoing colorectal surgery before our labelling.

Results: Patients’ characteristics in both groups were similar. The complications rate was similar in both groups. The global length of hospital stay was 4 [5] days vs. 8.5 [8] (median [IQR]), respectively after and before labelling; p?p?p?Conclusions: Our results demonstrate that labelling as reference centre increases the efficiency of the implementation of ERP. The fact that all subgroups of patients benefit from ERP must encourage inclusion of all patients undergoing elective colorectal surgery in ERP.     

Mortality and Complications in Patients with Metastatic Disease after Primary Total Hip and Total Knee Arthroplasty

BackgroundAlthough palliative therapies such as radiation are usually performed to improve quality of life in patients with metastatic disease, arthroplasty for joint pain may be indicated in some cases. Therefore, the purpose of this study is to evaluate the 30-day mortality risk, the risk of complications including infection and venous thromboembolic events, and the rate of 30-day reoperations and readmissions in patients with metastatic disease undergoing primary total hip and total knee arthroplasty (THA/TKA).MethodsWe reviewed the National Surgical Quality Improvement Program database from 2008 to 2018 to evaluate rates of postoperative complications after elective primary THA/TKA in patients with disseminated cancer. After exclusions, 205,007 patients undergoing primary THA and 352,337 undergoing primary TKA were retained for analysis: 942 (0.2%) with disseminated cancer. Chi-square was used to compare proportions between groups. Univariate and multivariate logistic regression was used to model the odds ratio of patients with disseminated cancer compared with those without disseminated cancer.ResultsAfter adjustment for covariates, patients with disseminated cancer had a higher risk of death (OR: 5.25, 95% CI: 2.47-11.17), any complication (OR: 1.95, 95% CI: 1.63-2.33), deep venous thrombosis (OR: 2.39, 95% CI: 1.32-4.35), pulmonary embolism (OR: 3.07, 95% CI: 1.52-6.17), cardiovascular complications (OR: 2.98, 95% CI: 1.47-6.04), transfusion (OR: 2.21, 95% CI: 1.82-2.69), reoperations (OR: 1.89, 95% CI: 1.28-2.78), readmissions (OR: 2.51, 95% CI: 1.95-3.23), and longer length of stay (4.3 vs 2.7 days).ConclusionPatients with disseminated cancer have significantly elevated risk of complications after elective primary THA/TKA. Understanding the severity of complications is critical to the risk-benefit analysis that confronts patients and surgeons considering surgery.Level of EvidenceII.     

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty

Background and purpose — The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifically blocking these nerves.

Patients and methods — We performed a single-center randomized placebo-controlled trial in 162 subjects to evaluate the infiltration of the lateral cutaneous femoral and subcostal nerve with ropivacaine in patients undergoing total hip arthroplasty via a straight lateral approach. The primary endpoint was pain at rest after 24?hours. Patients were followed up to 6 weeks postoperatively.

Results — After correction for multiple testing, no statistically significant differences in pain scores were found between the ropivacaine compared with the placebo group after surgery. In addition, no differences were observed in the use of escape pain medication, complications, and the length of hospital stay.

Interpretation — We found no clinically meaningful differences in pain scores between placebo and ropivacaine patients in the postoperative period after THA performed via a straight lateral approach under spinal anesthesia and a multimodal pain regimen. Moreover, our primary endpoint, pain reduction after 24?hours, was not met. Further research should focus on the composition and volume of the LIA suspension, the optimal localization of the infiltration, and should be evaluated for every surgical approach separately.     

Cannabis Use Does Not Affect Outcomes After Total Hip Arthroplasty

BackgroundCannabis use in patients undergoing arthroplasty has increased with ongoing legalization throughout the United States. The purpose of this study was to report total hip arthroplasty (THA) outcomes in patients self-reporting cannabis use.MethodsThere were 74 patients who underwent primary THA from January 2014 to December 2019 at a single institution with minimum 1-year follow-up who had their self-reported cannabis use retrospectively reviewed. Patients who had a history of alcohol or illicit drug abuse were excluded. A match control was conducted based on age; body mass index; sex; Charlson Comorbidity Index; insurance status; and use of nicotine, narcotics, antidepressants, or benzodiazepines to patients undergoing THA who did not self-report cannabis use. Outcomes included Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score for Joint Reconstruction (HOOS JR), in hospital morphine milligram equivalents (MMEs) consumed, outpatient MMEs prescribed, in hospital lengths of stay (LOS), postoperative complications, and readmissions.ResultsThere was no difference in the preoperative, postoperative, or change in Harris Hip Score or HOOS JR between cohorts. There was also no difference in hospital MMEs consumed (102.4 versus 101, P = .92), outpatient MMEs prescribed (119 versus 156, P = .11) or lengths of stay (1.4 versus 1.5 days, P = .32). Also, readmissions (4 versus 4, P = 1.0) and reoperations (2 versus 1, P = .56) were not different between groups.ConclusionSelf-reported cannabis use does not influence 1-year outcomes after THA. Further studies are warranted to determine the efficacy and safety of perioperative cannabis use after THA to help guide orthopaedic surgeons in counseling patients.     

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BackgroundHemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology.MethodsA multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status.ResultsThere were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status.ConclusionsBoth HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores.Level of EvidenceLevel III.     

Impact of Bariatric Surgery on Inpatient Complication,Cost, and Length of Stay Following Total Hip or Knee Arthroplasty

BackgroundMorbid obesity is an important risk factor for arthroplasty and also closely associated with worse postoperative outcomes. Bariatric surgery is effective in losing weight and decreasing comorbidities associated with obesity. However, no study had demonstrated the influence of bariatric surgery on the outcome of arthroplasty in a large population.MethodsWe used 2006-2014 discharge records from the Nationwide Inpatient Sample, and identified study population and inpatient complications by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis/procedure codes. Propensity score analysis was used to match total hip arthroplasty (THA) or total knee arthroplasty (TKA) patients with morbid obesity and THA or TKA patients with bariatric surgery.ResultsProportion of morbid obesity in both TKA and THA patients demonstrated a rising trend, while proportion of bariatric surgery in morbidly obese TKA and THA patients remains steady after 2007. For THA patients, there was fewer pulmonary embolism, more blood transfusion and anemia, and shorter length of stay in bariatric surgery group. For TKA patients, bariatric surgery group had a lower risk of pulmonary embolism, respiratory complications, death, and shorter length of stay, but bariatric surgery group had a higher risk of blood transfusion and anemia.ConclusionThere is evidence that bariatric surgery prior to arthroplasty, especially THA, appears to reduce rates of pulmonary complications and length of stay. But anemia and blood transfusion seem to be more common in patients with prior bariatric surgery.     

Does Hemophilia Increase Risk of Adverse Outcomes Following Total Hip and Knee Arthroplasty? A Propensity Score–Matched Analysis of a Nationwide,Population-Based Study

BackgroundEnd-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA.MethodsThis retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1:4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital.ResultsAfter propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval [CI] = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P < .001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups.ConclusionHemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA.     

Liposomal Bupivacaine Versus Bupivacaine/Epinephrine Intercostal Nerve Block as Part of an Enhanced Recovery After Thoracic Surgery (ERATS) Care Pathway for Robotic Thoracic Surgery

ObjectivesTo examine how postoperative pain control after robotic thoracoscopic surgery varies with liposomal bupivacaine (LipoB) versus 0.5% bupivacaine/1:200,000 epinephrine (Bupi/Epi) intercostal nerve blocks within the context of an enhanced recovery after thoracic surgery (ERATS) protocol.DesignA retrospective analysis of a prospectively maintained database of patients undergoing robotic thoracoscopic procedures between September 1, 2018 and October 31, 2019 was conducted.SettingUniversity of Miami, single-institutional.ParticipantsPatients.InterventionsTwo hundred fifty-two patients had either LipoB intercostal nerve blocks (n = 129) or Bupi/Epi intercostal nerve blocks (n = 123) when undergoing robotic thoracic surgery.Measurements and Main ResultsComparative analysis of patient-reported pain levels, in-hospital and post-discharge opioid requirements, 90-day operative complications, length of hospital stay, and hospital costs was performed. Data were stratified to either anatomic lung resection or pulmonary wedge resection/mediastinal-pleural procedures. Bupi/Epi patients reported significantly more acute postoperative pain than LipoB patients, which correlated with higher in-hospital and post-discharge opioid requirements. There were no differences in postoperative complications, length of hospital stay, or hospital costs between the two groups.ConclusionsAs part of an ERATS protocol, infiltration of intercostal spaces and surgical wounds with LipoB for robotic thoracoscopic procedures afforded better postoperative subjective pain control and decreased opioid requirements without an increase in hospital costs as compared with use of Bupi/Epi.     

Normal Pressure Hydrocephalus Is Associated With Increased Risks of Postoperative Complications Following Total Knee and Total Hip Arthroplasty

BackgroundNormal pressure hydrocephalus (NPH) has not been studied as a potential risk factor for postoperative complications after primary total knee (TKA) and total hip arthroplasty (THA).MethodsNearly 2000 patients with a diagnosis of NPH who underwent TKA or THA from 2005 to 2014 were identified in a national insurance database and compared to 10:1 matched controls using a logistic regression analysis.ResultsNPH was associated with an increased risk of hospital readmission, emergency room visit, and infection following TKA (odds ratio 1.48-2.70, all P < .01). NPH was associated with an increased risk of hospital readmission, emergency room visit, and dislocation following THA (odds ratio 2.40-2.50, all P < .01). NPH was also associated with significantly higher costs and hospital length of stay following both procedures.ConclusionThe diagnosis of NPH is associated with an elevated risk of postoperative complications and increased resource utilization following TKA and THA.     

Fast-track pathway for reduction of dislocated hip arthroplasty reduces surgical delay and length of stay

Background and purpose — Dislocation is one of the most common complications following hip arthroplasty. Delay until reduction leads to pain for the patient, and may increase the risk of complications. We investigated the safety aspect of a fast-track pathway for dislocated hip arthroplasties and evaluated its effect on surgical delay and length of stay (LOS).

Patients and methods — 402 consecutive and unselected dislocations (253 patients) were admitted at our institution between May 10, 2010 and September 31, 2013. The fast-track pathway for early reduction was introduced on January 9, 2011. Fast-track patients with a suspected dislocation (with no radiographic verification) were moved directly to the post-anesthesia care unit and then straight to the operating room. Dislocation was confirmed under fluoroscopy with reduction under general anesthesia. Surgical delay (in hours), LOS (in hours), perioperative complications, and complications during the hospital stay were recorded. Dislocation status for fast-track patients (confirmed or unconfirmed by fluoroscopy) was also recorded.

Results — Both surgical delay (2.5 h vs. 4.1 h; p < 0.001) and LOS (26 h vs. 31 h; p < 0.05) were less in patients admitted through the fast-track pathway than in patients on regular pathway. Perioperative complications (1.6% vs. 3.7%) and complications during the hospital stay (11% vs. 15%) were also less, but not statistically significantly so. Only 1 patient admitted through fast-track pathway had a fracture instead of a dislocation; all the other fast-track patients with suspected dislocation actually had dislocations.

Interpretation — The fast-track pathway for reduction of dislocated hip arthroplasty results in less surgical delay and in reduced LOS, without increasing perioperative complications or complications during the patient’s stay.     

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BackgroundThe purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.MethodsThis was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.ResultsFrom 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.ConclusionIn this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.Level of evidence3 (Retrospective cohort study).