Intranasal Low-Dose Dexmedetomidine Reduces Postoperative Opioid Requirement in Patients Undergoing Hip Arthroplasty Under General Anesthesia

Background

Patients undergoing total hip arthroplasty (THA) need substantial amount of opioids for postoperative pain management, which necessitates opioid-sparing modalities. Dexmedetomidine is a novel alpha-2-adrenoceptor–activating drug for procedural sedation. In addition to its sedative effect, dexmedetomidine has analgesic and antiemetic effects. We evaluated retrospectively the effect of intraoperatively administered intranasal low-dose dexmedetomidine on postoperative opioid requirement in patients undergoing THA.

Postoperative nausea and vomiting after bariatric surgery and dexmedetomidine anesthetic: a propensity-weighted analysis

BackgroundPatients undergoing laparoscopic bariatric surgery have high rates of postoperative nausea and vomiting (PONV). Dexmedetomidine based anesthetic could reduce PONV rates.ObjectivesTo determine if PONV rates differ in patients undergoing laparoscopic bariatric surgery with anesthesia primarily based on dexmedetomidine or standard anesthetic management with inhalational agents and opioids.SettingUniversity hospital.MethodsFrom January 2014 to April 2018, 487 patients underwent laparoscopic bariatric surgery and met inclusion criteria (dexmedetomidine, n = 174 and standard anesthetic, n = 313 patients). In both groups, patients received preoperative PONV prophylaxis. We analyzed rates of PONV and moderate-to-deep sedation. A propensity score was calculated and outcomes were assessed using generalized estimating equations with inverse probability of treatment weighting.ResultsPerioperative opioids and volatile anesthetics were reduced in dexmedetomidine patients. During anesthesia recovery the incidence of PONV was similar between dexmedetomidine and standard anesthetic patients (n = 37 [21.3%] versus n = 61 [19.5%], respectively; inverse probability of treatment weighting odds ratio = 1.35; 95% confidence interval .78–2.32, P = .281), and the incidence of sedation higher in dexmedetomidine patients (n = 86 [49.4%] versus n = 75 [24.0%]; inverse probability of treatment weighting odds ratio = 2.43; 95% confidence interval 1.47–4.03, P < 0.001). Rates of PONV and sedation were similar during the remainder of the hospital stay. A secondary sensitivity analysis was performed limited to dexmedetomidine patients who did not receive volatile and results were similar.ConclusionsWhile dexmedetomidine-based anesthesia was associated with reduced opioid and volatile agents use, it was not associated with a reduction of PONV. The higher rates of moderate-to-deep sedation during anesthesia recovery observed with dexmedetomidine may be undesirable in morbidly obese patients.     

Optimizing Rapid Recovery After Anterior Hip Arthroplasty Surgery: A Comparative Study of Fascia Iliaca Compartment Block and Local Infiltration Analgesia

BackgroundMultimodal pain therapy combining analgesics, local infiltration analgesia (LIA) and peripheral nerve blocks, such as fascia iliaca compartment block (FICB), can improve postoperative pain, nausea and vomiting (PONV) and ambulation in patients undergoing total hip arthroplasty (THA). We hypothesized that addition of FICB would decrease opioid requirements and length of stay (LOS) but could create a motor block.MethodsThis is a single center, prospective, blinded randomized controlled study of 152 patients undergoing elective THA via direct anterior approach from October 2019 till August 2021. Three patient groups were defined: patients receiving only spinal anesthesia (control group, n = 53); spinal anesthesia with LIA perioperatively (n = 50); and spinal anesthesia with FICB on the recovery unit (n = 49). Outcome measures consisted of postoperative pain scores, PONV, length of hospital stay, opioid requirements and mobility.ResultsOverall pain scores were low for all patient groups, with a lower pain score for LIA in comparison to the control group until 4 hours postoperatively (P < .05). Length of hospital stay, postoperative pain, nausea and vomiting (PONV) scores and quadriceps muscle strength did not differ significantly between groups. The control group showed higher scores at 12 hours postoperatively in comparison to FICB regarding rehabilitation potential, use of walking aids and activities of daily living (P < .05), but all groups reached the same endpoint 48 hours postoperatively. The LIA and FICB groups required less opioids until 24 hours postoperatively.ConclusionLIA is a beneficial adjuvant therapy to spinal anesthesia in THA patients as it may decrease pain scores and the need for opioid consumption. Adjuvant FICB only provided lower opioid requirements.     

The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols

BackgroundCompared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol.MethodsThis is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA.ResultsPatients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034).ConclusionNA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities.Level Of EvidenceLevel III Retrospective Cohort Study.     

Is Conversion TKA a Primary or Revision? Clinical Course and Complication Risks Approximating Revision TKA Rather Than Primary TKA

BackgroundConversion total knee arthroplasty (convTKA) is associated with increased resource utilization and costs compared with primary TKA. The purpose of this study is to compare 1) surgical time, 2) hospitalization length (LOS), 3) complications, 4) infection, and 5) readmissions in patients undergoing convTKA to both primary TKA and revision TKA patients.MethodsThe American College of Surgeons National Surgical Quality Improvement Project database was queried from 2008 to 2018. Patients undergoing convTKA (n = 1,665, 0.5%) were defined by selecting Current Procedural Terminology codes 27,447 and 20,680. We compared the outcomes of interest to patients undergoing primary TKA (n = 348,624) and to patients undergoing aseptic revision TKA (n = 8213). Univariate and multivariate logistic regression was performed to identify the relative risk of postoperative complications.ResultsCompared with patients undergoing primary TKA, convTKA patients were younger (P < .001), had lower body mass index (P < .001), and were less likely to be American Society of Anesthesiologist class III/IV (P < .001). These patients had significantly longer operative times (122.6 vs 90.3 min, P < .001), increased LOS (P < .001), increased risks for any complication (OR 1.94), surgical site infection (OR 1.84), reoperation (OR 2.18), and readmissions (OR 1.60) after controlling for confounders. Compared with aseptic TKA revisions, operative times were shorter (122.6 vs 148.2 min, P < .001), but LOS (2.91 vs 2.95 days, P = .698) was similar. Furthermore, relative risk for any complication (P = .350), surgical site infection (P = .964), reoperation (P = .296), and readmissions (P = .844) did not differ.ConclusionConversion TKA procedures share more similarities with revision TKA rather than primary TKA procedures. Without a distinct procedural and diagnosis-related group, there are financial disincentives to care for these complex patients.Level of EvidenceII.     

Comparison Study of Patient Demographics,Risk Factors,and Lengths of Stay for Postoperative Ileus After Primary Total Knee Arthroplasty

BackgroundPostoperative ileus is a potential complication after orthopedic surgery, which has not been well studied after total knee arthroplasty (TKA). The aims of this study were to analyze rates of postoperative ileus; patient demographic profiles; in-hospital lengths of stay (LOS); and patient-related risk factors for postoperative ileus after primary TKA.MethodsA query was performed from January 1, 2005 to March 31, 2014 using the Medicare Standard Analytical Files. Patients who underwent primary TKA and developed postoperative ileus within 3 days after their index procedure were identified. Patients who did not develop ileus represented controls. Primary outcomes analyzed and compared included patient demographics, risk factors, and in-hospital LOS. A P value less than .05 was considered statistically significant.ResultsIleus patients were older, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (8 vs 6; P < .0001) compared with controls. Male patients (odds ratio [OR], 2.12; P < .0001), patients with preoperative electrolyte/fluid imbalance (OR, 3.40; P < .001), patients older than 70 years (OR, 1.62-2.33; P < .015), and body mass indices greater than 30 kg/m² (OR, 1.79-2.00; P < .001) were at the greatest risk of developing ileus. In addition, ileus patients had significantly longer in-hospital LOS (5.42 vs 3.22 days; P < .001).ConclusionThe study demonstrated differences in patient demographics, patient-related risk factors, and an increased in-hospital LOS for ileus patients after primary TKA. The study is important as it can allow orthopedists to properly identify and optimize patients with certain risk factors to potentially mitigate this adverse event from occurring.     

Computer-Navigated and Robotic-Assisted Total Knee Arthroplasty: Increasing in Popularity Without Increasing Complications

BackgroundData on the clinical impact of computer navigation (CN) and robotic assistance (RA) in total knee arthroplasty (TKA) are mixed. This study aims to describe modern utilization trends in CN-TKA, RA-TKA, and traditionally-instrumented (TD) TKA and to assess for differences in postoperative complications and opioid consumption by procedure type.MethodsA national database was queried to identify primary, elective TKA patients from 2015 to 2020. Trends in procedural utilization rates were assessed. Differences in 90-day postoperative complications and inpatient opioid consumption were assessed. Multivariate regression analyses were performed to account for potential confounders.ResultsOf the 847,496 patients included, 49,317 (5.82%) and 24,460 (2.89%) underwent CN-TKA and RA-TKA, respectively. CN-TKA utilization increased from 5.64% (2015) to 6.41% (2020) and RA-TKA utilization increased from 0.84% (2015) to 5.89% (2020). After adjusting for confounders, CN-TKA was associated with lower periprosthetic joint infection (P = .001), pulmonary embolism (P < .001), and acute respiratory failure (P = .015) risk compared to traditional (TD) TKA. RA-TKA was associated with lower deep vein thrombosis (P < .001), myocardial infarction (P = .013), and pulmonary embolism (P = .001) risk than TD-TKA. Lower postoperative day 1 opioid usage was seen with CN-TKA and RA-TKA than TD-TKA (P < .001). Lower postoperative day 0 opioid consumption was also seen in RA-TKA (P < .001).ConclusionFrom 2015 to 2020, there was a relative 13.7% and 601.2% increase in CN-TKAs and RA-TKAs, respectively. This trend was associated with reductions in hospitalization duration, postoperative complications, and opioid consumption. These data support the safety of RA-TKA and CN-TKA compared to TD-TKA. Further investigation into the specific indications for these technology-assisted TKAs is warranted.     

Trends in Length of Stay and 30-Day Complications After Total Knee Arthroplasty: An Analysis From 2006 to 2016

BackgroundHospital length of stay (LOS) is a quality metric and target of recent efforts in the last decade to decrease healthcare costs and postoperative nosocomial complications after total knee arthroplasty (TKA). However, decreasing LOS has raised concerns of possible increased complication and readmission rates. We present a decade-long analysis in trends of LOS and 30-day complication and unplanned readmissions following TKA.MethodsThe National Surgical Quality Improvement Program registry was utilized to identify patients undergoing elective primary TKA between 2006 and 2016. Three cohorts of patients were created based on year of surgery (2006-2009 [N = 7111], 2010-2013 [N = 71,943], and 2014-2016 [N = 142,710]). Patient demographics, perioperative variables, LOS, 30-day postoperative complications, and readmission rates were analyzed between the 3 cohorts using bivariate and multivariate analyses.ResultsLOS decreased significantly over time when the 2006-2009 cohort (3.7 days) was compared to the 2010-2013 cohort (3.3 days, P < .001) and 2014-2016 cohort (3.0 days, P < .001). Similarly, there was a decrease in the rate of total 30-day complications in the 2006-2009 cohort (5.37%) compared to 2010-2013 (3.86%) and 2014-2016 (3.13%, P < .001), with significantly lower rates of deep vein thrombosis, sepsis, and urinary tract infection in the latter cohorts. Decreasing rates of 30-day readmission were also observed in the 2010-2013 cohort (3.63%) compared to 2013-2016 cohort (3.23%, P < .001).ConclusionIn the last decade, there has been a trend toward decreasing LOS after TKA. Despite concerns about early discharge, data from a national registry demonstrated a simultaneous decrease in total 30-day complication and readmission rates.Level of EvidenceIII, Retrospective cohort study.     

General vs Spinal Anesthesia for Revision Total Knee Arthroplasty: Do Complication Rates Differ?

BackgroundThe incidence of both primary total knee arthroplasty (TKA) and revision TKA is increasing. Data from primary arthroplasty patients suggest a risk reduction with the use of spinal anesthesia when compared with general anesthesia. However, the same relationship has not been examined in the revision knee arthroplasty patient.MethodsThis is a retrospective cohort study using the American College of Surgeons-National Surgical Quality Improvement database. Patients undergoing revision TKA with either spinal or general anesthesia were identified from the database. Baseline characteristics were compared, and ultimately patients were matched using coarsened exact matching. Multivariate analysis was then performed on matched cohorts controlling for baseline patient and operative characteristics. This model was used to look for any differences in rates of complications, operative time, length of stay, and readmission.ResultsPatients undergoing revision TKA with general anesthesia had increased risk of several postoperative complications, even after controlling for baseline patient characteristics. Specifically, there were significantly increased rates of the following: unplanned readmission (OR = 1.43, 95% confidence interval [CI] = 1.18-1.72, P < .001), nonhome discharge (OR = 1.60, 95% CI = 1.46-1.76, P < .001), transfusion (OR = 1.63, 95% CI = 1.41-1.88, P < .001), deep surgical site infection (OR = 1.43, 95% CI = 1.01-2.03, P = .043), and extended length of stay (OR = 1.22, 95% CI = 1.11-1.34, P < .001). General anesthesia was additionally associated with increased operative time.ConclusionGeneral anesthesia is associated with increased risk of numerous postoperative complications in patients undergoing revision TKA. This study is retrospective in nature, and while causality cannot be definitively determined, the results suggest that spinal anesthesia is preferential to general anesthesia in the revision TKA patient.     

Impact of ultrasound-guided erector spinae plane block on postoperative quality of recovery in video-assisted thoracic surgery: A prospective,randomized, controlled trial

Study objectiveRegional anesthesia improves postoperative analgesia and enhances the quality of recovery (QoR) after surgery. We examine the efficacy of ultrasound-guided erector spinae plane block (ESPB) on QoR after video-assisted thoracic surgery (VATS).DesignProspective, randomized, double-blinded, placebo-controlled trial.SettingSingle institution, tertiary university hospital.PatientsAdult patients who scheduled for VATS under general anesthesia were enrolled in the study.InterventionsWe randomly allocated patients to receive preoperative ultrasound-guided ESPB with 25 ml of either 0.5% ropivacaine (ESPB group) or normal saline (Control group).MeasurementsThe primary outcome was QoR as measured by the 40-item QoR questionnaire (QoR-40) score at postoperative day 1. Secondary results were post-anesthesia care unit (PACU) discharge time, acute postoperative pain, cumulative opioid consumption, the incidence of postoperative nausea or vomiting (PONV), and patient satisfaction.Main resultsThe global QoR-40 score at postoperative day 1 (median, interquartile range) was significantly higher in the ESPB group (174, 170 to 177) than the control group (161.5, 160 to 165), estimated median difference 11 (95% CI 9 to 13, P < 0.001). Compared with the control group, single-injection of ESPB reduced PACU discharge time, acute postoperative pain, and cumulative opioid consumption. Correspondingly, the median patient satisfaction scores were higher in the ESPB group than the control group (9 versus 7, P < 0.001).ConclusionPreoperative single-injection thoracic ESPB with ropivacaine improves QoR, postoperative analgesia, and patient satisfaction after VATS.     

Frailty,Race/Ethnicity,Functional Status,and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

BackgroundAlthough frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.MethodsThe National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.ResultsWe identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.ConclusionDisparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.     

Levobupivacaine vs racemic bupivacaine in spinal anesthesia for sequential bilateral total knee arthroplasty: a retrospective cohort study

Study objectivesTo compare the anesthetic potency and safety of spinal anesthesia with higher dosages of levobupivacaine and bupivacaine in patients for bilateral sequential for total knee arthroplasty (TKA).DesignRetrospective cohort study.SettingOperation theater with postoperative inpatient follow-up.PatientsThe medical records of 315 patients who underwent sequential bilateral TKA were reviewed.InterventionsPatients who received intrathecal levobupicavaine 0.5% were compared with patients who received hyperbaric bupivacaine 0.5% with fentanyl 25 μg for spinal anesthesia.MeasurementsThe primary outcome was the use of rescue analgesia (systemic opioids, conversion to general anesthesia) during surgery for both groups. Secondary outcomes included adverse effects of local anesthetics (hypotension and bradycardia) during surgery and morbidity related to spinal anesthesia (postoperative nausea, vomiting, and bleeding) during hospital stay.Main resultsOne hundred fifty patients who received intrathecal levobupivacaine 0.5% (group L) were compared with 90 patients given hyperbaric bupivacaine 0.5% with fentanyl 25 μg (group B). The mean volume of levobupivacaine administered was 5.8 mL (range, 5.0-6.0 mL), and that of bupivacaine was 3.8 mL (range, 3.5-4.0 mL). Both groups achieved similar maximal sensory level of block (T6). The time to maximal height of sensory block was significantly shorter in group B than group L, 18.2 ± 4.5 vs 23.9 ± 3.8 minutes (P< .001). The time to motor block of Bromage 3 was also shorter in group B (8.7 ± 4.1 minutes) than group L (16.0 ± 4.5 minutes) (P< .001). Patients in group B required more anesthetic supplement than group L (P< .001). Hypotension and postoperative bleeding were significantly less common in group L than group B.ConclusionLevobupivacaine at a higher dosage provided longer duration of spinal anesthesia with better safety profile in sequential bilateral TKA.     

A Comparison of Neuraxial and General Anesthesia for Thirty-Day Postoperative Outcomes in United States Veterans Undergoing Total Knee Arthroplasty

BackgroundThe aim of this study is to investigate which anesthetic technique is superior on 30-day outcomes after primary total knee arthroplasty (TKA) in United States veteran patients. To our knowledge, this is the first account from the Veterans Health Administration comparing the effects of different anesthesia modalities in patients undergoing TKA.MethodsThe Veterans Affairs Surgical Quality Improvement Program database was utilized to analyze patients undergoing primary TKA during the period of 2008-2015. Subjects were divided into 2 cohorts based on the method of surgical anesthesia used: general anesthesia or neuraxial anesthesia. Propensity score matching was utilized to avoid possible selection bias between the 2 cohorts when assessing patient demographics and comorbidities. The 2 groups were analyzed for 30-day postoperative complications, using multivariable logistic regression techniques to evaluate independent associations between anesthetic method and postoperative outcomes.ResultsAll Veterans Affairs patients undergoing primary TKA under general anesthesia (n = 32,363) and neuraxial anesthesia (n = 14,395) within the study period were included in this study. Following propensity score matching, multivariable analysis revealed significantly lower risks of cardiovascular (adjusted odds ratio [AOR] 0.74, 95% confidence interval [CI] 0.6-0.88, P < .001), respiratory (AOR 0.75, 95% CI 0.57-0.97, P = .03), and renal complications (AOR 0.62, 95% CI 0.4-0.9, P = .01) in patients receiving neuraxial anesthesia compared to those receiving general anesthesia. Neuraxial anesthesia was also associated with reduced hospital stay and lower odds of prolonged hospitalization (AOR 0.85, 95% CI 0.8-0.9, P < .001).ConclusionVeteran patients undergoing TKA under neuraxial anesthesia had reduced postoperative complications and decreased hospitalization stay compared to patients undergoing general anesthesia.     

Patients With Multiple Sclerosis are at Increased Risk for Postoperative Complications Following Total Hip and Knee Arthroplasty

BackgroundMultiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system. Patients with MS are living longer due to improved medical therapy and thus the demand for arthroplasty in this population will increase. The objective of this study is to evaluate MS as a potential risk factor for postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsPatients with a diagnosis of MS who underwent THA or TKA from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visits, infection, revision, and dislocation (for THA) or stiffness (for TKA) were calculated, in addition to cost and length of stay. MS patients were then compared to a matched control population.ResultsIn total, 3360 patients who underwent THA and 6436 patients who underwent TKA with a history of MS were identified and compared with 10:1 matched control cohorts without MS. The MS group for both TKA and THA had significantly higher incidences of hospital readmission (THA odds ratio [OR] 2.05, P < .001; TKA OR 1.99, P < .001), emergency room visits (THA OR 1.41, P < .001; TKA OR 1.66, P < .001), and infection (THA OR 1.35, P = .001; TKA OR 1.32, P < .001). MS patients who underwent THA had significantly higher rates of revision (OR 1.35, P = .001) and dislocation (OR 1.52, P < .001). Diagnosis of MS was also associated with significantly higher costs and hospital length of stay for patients undergoing both TKA and THA.ConclusionA diagnosis of MS is associated with increased risk of postoperative complications and higher costs following both THA and TKA.     

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.     

Chronic Opioid Use Independently Increases Complications and Resource Utilization After Primary Total Joint Arthroplasty

BackgroundCurrent literature suggests a link between the chronic use of opioids and musculoskeletal surgical complications. Given the current opioid epidemic, the need to elucidate the effects of chronic opioid use (OD) on patient outcomes and cost has become important. The purpose of this study was to determine if OD is an independent risk factor for inpatient postoperative complications and resource utilization after primary total joint arthroplasty.MethodsA total of 3,545,565 patients undergoing elective, unilateral, primary total hip (THA) and knee (TKA) arthroplasty for osteoarthritis from January 2016 to December 2019 were identified using a large national database. In-hospital postoperative complications, length of stay, and total costs adjusted for inflation in opioid + patients were compared with patients without chronic opioid use (OD). Logistic regression analyses were used to control for cofounding factors.ResultsOD patients undergoing either THA or TKA had a higher risk of postoperative complications including respiratory (odds ratio (OR): 1.4 and OR: 1.3), gastrointestinal (OR: 1.8 and OR: 1.8), urinary tract infection (OR: 1.1 and OR: 1.2), blood transfusion (OR: 1.5 and OR: 1.4), and deep vein thrombosis (OR: 1.7 and OR: 1.6), respectively. Total cost ($16,619 ± $9,251 versus $15,603 ± $9,181, P < .001), lengths of stay (2.15 ± 1.37 versus 2.03 ± 1.23, P < .001), and the likelihood for discharge to a rehabilitation facility (17.8 versus 15.7%, P < .001) were higher in patients with OD.ConclusionOD was associated with higher risk for in-hospital postoperative complications and cost after primary THA and TKA. Further studies to find strategies to mitigate the impact of opioid use on complications are required.     

Narcotic Consumption in Opioid Naïve Patients Undergoing Unicompartmental and Total Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to unicompartmental knee arthroplasty (UKA). The purpose of the current study is to compare acute postoperative narcotic consumption between the 2 procedures and quantify narcotic consumption.MethodsFrom October 2017 to August 2019 patients were surveyed for four weeks to determine the amount and duration of opioids consumed and requirement for continued narcotics. Among 976 opioid naïve patients, 314 (32%) underwent UKA and 662 (68%) underwent TKA. Patients were analyzed according to specific narcotic prescribed. Total morphine equivalent dose (MED), number of pills, duration, refill percentage, and usage percentage for 4 weeks were calculated for each procedure.ResultsMED used in the postoperative period was lower in patients undergoing UKA than TKA (200 ± 195 vs 259 ± 250 MED, P = .002). Total number of pills consumed and duration of use was less in UKA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics for 4 weeks after UKA (32% vs 43%, P < .001), and fewer UKA patients required narcotic refills (14% vs 27%, P < .001). Sixty pills of any 1 type of narcotic was sufficient for 90% of UKA patients and over 75% of TKA patients.ConclusionUKA is associated with less narcotic consumption, shorter duration of use, less refills, and lower likelihood of narcotic requirement for 4 weeks. We report narcotic consumption patterns for both procedures to aid surgeons in judicious postoperative prescribing.Level of EvidenceThis is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid naïve patients undergoing UKA or TKA.     

Operative Times Can Predict and Are Correlated With Lengths-of-Stay in Primary Total Knee Arthroplasty: A Nationwide Database Study

BackgroundThe specific influence of operative times on lengths-of-stay (LOS) has not been well assessed and is therefore an important topic of evaluation for multiple reasons, including potential economic implication. The purpose of this study is to (1) identify predictors of longer operative times; (2) identify predictors of longer LOS; and (3) evaluate the effects of operative times on LOS in primary total knee arthroplasty (TKA).MethodsThe National Surgical Quality Improvement Program database was queried for primary TKAs performed between 2008 and 2016, yielding 225,344 cases. Multivariate analysis was performed to determine the effect of operative times on LOS after adjusting for patient factors. Univariate analyses were performed with 1-way analysis of variance (ANOVA), linear regression, and independent sample t-tests where appropriate. Multivariate analysis was performed with a multiple linear regression model adjusted for patient age, sex, and body mass index (BMI).ResultsThe mean operative time was 93 ± 35 minutes and the mean LOS was 3 ± 3 days. Young age, male sex, and obesity were predictors of longer operative times (P < .001). Similarly, there were significant associations of age, sex, and BMI with LOS (P < .001). Increasing 30-minute operative time intervals were associated with increasing LOS (P < .001). Longer operative times had significant associations with longer LOS even after adjusting for patient factors (β = 0.076, SE < 0.001, P value < .001). Out of all study covariates, operative times had the greatest effect on LOS.ConclusionThis study provides unique insight by directly correlating operative times to LOS in over 200,000 TKAs. The results from this study indicate that there is a strong correlation between operative times and LOS, so that operative time had a greater association than age, sex, and BMI with postoperative TKA LOS.     

Differences in Pain,Opioid Use,and Function Following Unicompartmental Knee Arthroplasty compared to Total Knee Arthroplasty

BackgroundWe sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA).MethodsA single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019.ResultsIn total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed.ConclusionUKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes.Level III EvidenceRetrospective Cohort Study.