Same-Day Discharge Total Hip and Knee Arthroplasty: Trends,Complications, and Readmission Rates

BackgroundAlthough total hip arthroplasty (THA) and total knee arthroplasty (TKA) are transitioning to surgery centers, there remain limited data on trends, comorbidities, and complications in patients discharged the same day of surgery. In addition, many studies are limited to the Medicare population, excluding a large proportion of outpatient surgery patients.MethodsPrimary, elective THA/TKA cases between 2010 and 2017 were retrospectively identified using the PearlDiver All-Payer Database and separated based on surgery as well as same-day discharge (SDD) or non-SDD. Data were collected on demographics, rates, comorbidities, and complications. Multivariable logistic regression determined adjusted odds ratios (ORs) for 90-day complications requiring readmission for each group.ResultsIn total, 1,789,601 (68.8% TKA, 31.2% THA) patients were identified where 2.9% of TKAs and 2.2% of THAs were SDD. Annual SDD rates are increasing, with a 15.8% mean annual change for SDD-THA and 11.1% for SDD-TKA (P < .001). SDD patients were younger with fewer comorbidities (P < .001). Regression analysis showed an overall slightly higher OR of complications requiring readmission for SDD-TKA vs non-SDD-TKA (OR 1.14, 95% confidence interval [CI] 1.07-1.21, P < .001). There was no significant difference for SDD-THA vs non-SDD-THA (OR 1.03, 95% CI 0.94-1.13, P = .49). In univariate analysis, SDD-THA vs SDD-TKA had more mechanical complications (P < .001), but less pulmonary embolisms (P < .001). Regression analysis showed a slightly higher risk of complications for SDD-THA vs SDD-TKA (OR 1.19, 95% CI 0.99-1.44, P = .05).ConclusionThe prevalence of SDD is rising. SDD-THA is increasing more rapidly than SDD-TKA. SDD patients are generally younger with fewer comorbidities. SDD-TKA has slightly higher odds of complications requiring readmission than non-SDD-TKA. SDD-THA and SDD-TKA have different complication profiles.     

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery

BackgroundPostoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear.ObjectivesWe aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.MethodsThe MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits.ResultsOf 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30–23.27; P < .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22–8.46; P < .001), wound disruption (AOR, 4.63; 95% CI, 3.09–6.96; P < .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38–4.28; P < .001).ConclusionsPostoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits.     

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.     

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study

BackgroundAs the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes.MethodsIn this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression.ResultsIn total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001).ConclusionTHA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.     

A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score

BackgroundUnplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer.MethodsThis was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival.ResultsA total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9–7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed.ConclusionComorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.     

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BackgroundWe examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.MethodPatient information was retrieved from the Nationwide Readmission Database (2010–2017). Multivariate analysis was used to identify predictors for hospital readmissions.ResultsA total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13–3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04–2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473–1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84–3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076–1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976–2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03–1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11–1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.ConclusionConcomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.     

Revision Joint Arthroplasty and Renal Transplant: A Matched Control Cohort Study

BackgroundThere is little literature concerning clinical outcomes following revision joint arthroplasty in solid organ transplant recipients. The aims of this study are to (1) analyze postoperative outcomes and mortality following revision hip and knee arthroplasty in renal transplant recipients (RTRs) compared to non-RTRs and (2) characterize common indications and types of revision procedures among RTRs.MethodsA retrospective Medicare database review identified 1020 RTRs who underwent revision joint arthroplasty (359 revision total knee arthroplasty [TKA] and 661 revision total hip arthroplasty [THA]) from 2005 to 2014. RTRs were compared to their respective matched control groups of nontransplant revision arthroplasty patients for hospital length of stay, readmission, major medical complications, infections, septicemia, and mortality following revision.ResultsRenal transplantation was significantly associated with increased length of stay (6.12 ± 7.86 vs 4.33 ± 4.29, P < .001), septicemia (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.83-3.46; P < .001), and 1-year mortality (OR, 2.71; 95% CI, 1.51-4.53; P < .001) following revision TKA. Among revision THA patients, RTR status was associated with increased hospital readmission (OR, 1.23; 95% CI, 1.03-1.47; P = .023), septicemia (OR, 1.82; 95% CI, 1.41-2.34; P < .001), and 1-year mortality (OR, 2.65; 95% CI, 1.88-3.66; P < .001). The most frequent primary diagnoses associated with revision TKA and THA among RTRs were mechanical complications of prosthetic implant.ConclusionPrior renal transplantation among revision joint arthroplasty patients is associated with increased morbidity and mortality when compared to nontransplant recipients.     

What Are Drivers of Readmission for Readmission-Requiring Venous Thromboembolic Events After Primary Total Hip Arthroplasty? An Analysis of 544,443 Cases

BackgroundVenous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission.MethodsThe Agency of Healthcare Research and Quality’s National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities.ResultsHigher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05).ConclusionOne in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE complications.     

Relative Contribution of Outpatient Arthroplasty Risk Assessment Score Medical Comorbidities to Same-Day Discharge After Primary Total Joint Arthroplasty

BackgroundSelection of patients who can safely undergo outpatient total joint arthroplasty (TJA) is an increasing priority given the growth of ambulatory TJA. This study quantified the relative contribution and weight of 52 medical comorbidities comprising the Outpatient Arthroplasty Risk Assessment (OARA) score as predictors of safe same-day discharge (SDD).MethodsThe medical records of 2748 primary TJAs consecutively performed between 2014 and 2020 were reviewed to record the presence or absence of medical comorbidities in the OARA score. After controlling for patients not offered SDD due to OARA scores and patients who were offered but declined SDD, the final analysis sample consisted of 631 cases, 92.1% of whom achieved SDD and 7.9% of whom did not achieve SDD. Odds ratios were calculated to quantify the extent to which each comorbidity is associated with achieving SDD.ResultsDemographic characteristics of analysis cases were consistent with a high-volume TJA practice in a US metropolitan area. Among testable OARA comorbidities, 53% significantly decreased the likelihood of SDD by 2.3 (body mass index [BMI] ≥40 kg/m²) to 12 (history of post-operative confusion and pacemaker dependence) times. BMI between 30 and 39 kg/m² did not affect the likelihood of SDD (P = .960), and BMI ≥40 kg/m² had the smallest odds ratio in our study (2.28, 95% confidence interval 1.11-4.67, P = .025).ConclusionStudy findings contribute to the refinement of the OARA score as a successful predictor of safe SDD following primary TJA while maintaining low 90-day readmission rates.     

Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty

BackgroundAs ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence.MethodsPatients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression.ResultsThe most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD.ConclusionsThe most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates

BackgroundActive patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.MethodsThe National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.ResultsOf 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).ConclusionCemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.Level of EvidenceLevel III.     

Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis

Study objectiveIt has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty.DesignPropensity-matched cohort analysis.SettingAmerican College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021.PatientsPatients undergoing elective total hip arthroplasty (n = 223,060).InterventionsNone.MeasurementsThe a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses.Main resultsThe 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, −0.09 [95% CI, −0.12 to −0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021.ConclusionsTotal hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.     

Predictors of Acute Kidney Injury in Deceased Kidney Donors After Brain Death

BackgroundDonors with acute kidney injury (AKI) are generally accepted as a valuable source of kidneys for transplant. The aim of this study was to assess the risk of developing AKI based on deceased kidney donor parameters.Materials and MethodsThe data of 162 kidneys procured from deceased donors after brain death were collected. These included clinical characteristics of donors and histologic assessment in organ biopsy specimens. The donors’ kidney terminal function was classified according to the Acute Kidney Injury Network criteria. All biopsies were performed with the use of a 16G automatic needle, and the 20-mm tissue specimen was available in all cases. Biopsy specimens were secured and prepared in a routine way with hematoxylin and eosin. The presence of chronic changes was analyzed according to the Banff 2009 classification by 1 experienced nephropathologist. The logistic regression model was used to assess the risk of AKI regarding donor characteristics and histologic findings.ResultsThere were 50 kidneys (30.9%) with AKI identified. The risk of AKI increased with donor age (P = .002; odds ratio [OR], 1.02; 95% CI, 1.01–1.03), body mass index (P = .003; OR, 1.05; 95% CI, 1.01–1.09), and male sex (P = .001; OR, 1.79; 95% CI, 1.31–2.27). Regarding the histologic findings, the interstitial fibrosis presence was a risk factor of AKI (P = .004; OR, 1.04; 95% CI, 1.01–1.06).ConclusionsOlder donor age, male sex, higher body mass index, and presence of interstitial fibrosis in kidney graft biopsy specimen are risk factors of AKI.     

Black-versus-White racial disparities in 30-day outcomes at Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited centers: a needed quality indicator

BackgroundCreating a metric in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to assess Black-versus-White disparities is critical if we are to ensure equitable care for all.ObjectiveTo investigate Black-versus-White disparities while replicating MBSAQIP methodology with regard to covariates and modeling so that the results can serve as the foundation to create a benchmarked site-level Disparities Metric for MBSAQIP.SettingUnited States and Canada.MethodsAcross the 2015–2019 MBSAQIP cohorts, 543,976 adults underwent primary or revision sleeve gastrectomy or Roux-en-Y gastric bypass and were reported as either White or Black. Using a set of covariates derived from published MBSAQIP performance models, we performed multivariable logistic modeling with 10-fold cross-validation for the 11 outcomes evaluated in MBSAQIP Semiannual Reports, plus venous thromboembolism (VTE) and death. We analyzed primary and revision cases separately.ResultsAfter risk adjustment, Black patients experienced higher odds of all-occurrence morbidity (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19–1.25; P < .001), serious events (OR, 1.08; 95% CI, 1.04–1.13; P < .001), all-cause intervention (OR, 1.31; 95% CI, 1.24–1.37; P < .001), related intervention (OR, 1.29; 95% CI, 1.22–1.37; P < .001), all-cause readmission (OR, 1.37; 95% CI, 1.33–1.41; P < .001), related readmission (OR, 1.41; 95% CI, 1.36–1.46; P < .001), venous thromboembolism (OR, 1.49; 95% CI, 1.34–1.65; P < .001), and death (OR, 1.59; 95% CI, 1.34–1.89; P < .001) after primary procedures. Black patients experienced lower odds of morbidity (OR, .94; 95% CI, .91–.98; P = .004) and surgical-site infection (OR, .72; 95% CI, .66–.78; P < .001).ConclusionsBlack patients experienced a higher risk for serious complications and required more readmissions, reoperations, and postoperative interventions. This study supports the creation of a site-level Disparities Metric for the MBSAQIP and provides the framework to do so.     

An analysis of readmission trends by urgency and race/ethnicity in the MBSAQIP registry, 2015–2018

BackgroundLarge-scale analyses stratifying bariatric surgery readmissions by urgency are lacking.ObjectivesIdentify predictors of urgent/nonurgent readmission among “ideal” bariatric candidates, using a national registry.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database.MethodsWe extracted an “ideal” patient cohort from the 2015–2018 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) registry, characterized by only typical weight-related comorbidities (hypertension [HTN], obstructive sleep apnea [OSA], gastroesophageal reflux disease [GERD], and diabetes (insulin-dependent diabetes mellitus [IDDM] and non–insulin-dependent diabetes mellitus [NIDDM]) undergoing primary bariatric surgery with an uneventful postoperative course. Readmissions were classified as “urgent” (UR; e.g., leak, obstruction, bleeding) or “nonurgent” (NUR; e.g., dehydration, nonspecific abdominal pain). χ² or t test analyses were used for bivariate significance testing. Multivariate logistic regression models were constructed to assess independent predictors of readmission.ResultsThe cohort (N = 292,547) comprised 38.5% of all MBSAQIP patients (mean age [standard deviation] = 43.2 [11.7]; body mass index [BMI] = 44.9 [6.6]; 81% female; 62% White, 17% Black, 14% Hispanic). Total readmission rates were 2.75% (n = 8046) and decreased from 2015–2018 (3.00%–2.63%; P < .001). Independent predictors of readmissions included Roux-en-Y gastric bypass (RYGB) (odds ratio [OR] = 1.97, p < .001), Black (OR = 1.46, P < .001) and Hispanic race (OR = 1.14, P < .001), GERD (OR = 1.27, P < .001), HTN (OR = 1.08, P = .003), and IDDM (OR = 1.39, P < .001). NUR and UR readmission rates were 1.27% (n = 3702) and 1.06% (n = 3090), respectively. NURs decreased over time (1.42%–1.16%, P < .001), with no change in Urs (1.01%–1.06%, P = .51); this trend persisted in multivariate analysis (2017: NUR OR = .85, P < .001; 2018: NUR OR = .82, p < .001). Independent predictors of both URs and NURs included Black (NUR OR = 1.71, p < .001; UR OR = 1.27, p < .001) and Hispanic (NUR OR = 1.15, P < .001; UR OR = 1.19, P < .001) race, RYGB (NUR OR = 1.84, P < .001; UR OR = 2.34, P < .001), and GERD (NUR OR = 1.39, p < .001; UR OR = 1.17, P < .001). Female sex (NUR OR = 1.64, P < .001), age (NUR OR = .98, P < .001), HTN (NUR OR = 1.22, P < .001), and IDDM (NUR OR = 1.41, P < .001) predicted NURs, while higher BMI (UR OR = 1.01, P < .001), and OSA (UR OR = 1.10, P = .02) predicted URs.ConclusionReadmission rates for “ideal” bariatric patients improved over time, driven by reductions in non-urgent etiologies. Racial disparities persist for both urgent and non-urgent causes of readmission.     

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.     

Effect of Preoperative Right Ventricular Dysfunction on Heart Transplantation Outcomes

BackgroundWe investigated if the occurrence of preoperative right ventricular dysfunction is capable of influencing heart transplant results in terms of in-hospital mortality, incidence of primary graft dysfunction, and follow-up mortality.MethodsWe retrospectively analyzed 517 patients who underwent heart transplant between January 2000 and December 2020. We defined right ventricular dysfunction (RVD), as central venous pressure (CVP) > 15 mm Hg and CVP/pulmonary capillary wedge pressure ratio > 0.63. We identified 2 subgroups in our population: 33 patients with preoperative RVD and 484 patients without RVD.ResultsIn-hospital mortality was 7.9%. Severe early graft failure occurred in 6.6% of patients, with 26 patients (5.1%) needing intra-aortic balloon pump and 17 patients (3.3%) needing extracorporeal membrane oxygenation support. Clinical variables that significantly influenced in-hospital mortality were age, peripheral artery disease, and bilirubin > 1.5 mg/dL, while hemodynamic variables influencing in-hospital mortality were CVP (odds ratio [OR], 1.09 [confidence interval {CI}, 1.03-1.15], P = .004], pulmonary artery systolic pressure (OR, 1.02 [CI, 1.00-1.04], P = .05), CVP/pulmonary capillary wedge pressure ratio (OR, 2.78 [CI, 1.14-6.80], P = .025), pulmonary vascular resistance (OR, 1.15 [CI, 1.01-1.32], P = .042), transpulmonary gradient (TPG) (OR, 1.11 [CI, 1.03-1.18], P = .003) , diastolic transpulmonary gradient (OR, 1.10 [CI, 1.02-1.20], P = .015], together with right ventricular dysfunction (OR, 3.56 [CI, 1.44-8.80], P = .011). On the other hand, clinical variables influencing the incidence of early graft failure were body mass index (calculated as weight in kilograms divided by height in meters squared) > 30, peripheral artery disease, bilirubin > 1.5 mg/dL, Model for End-Stage Liver Disease score excluding international normalized ratio before transplant, and preoperative extracorporeal membrane oxygenation support, while hemodynamic variables were pulmonary arterial systolic pressure (OR, 1.03 [CI, 1.00-1.05], P = .016), TPG (OR, 1.08 [1.01-1.17], P = .03), and right ventricular dysfunction (OR, 3.00 [CI, 1.07-8.40] P = .046). On the multivariable analysis, RVD and TPG were independent predictors of in-hospital mortality, while only TPG was a predictor of early graft failure. Follow-up mortality was 38.7% and was influenced by recipient age, recipient body mass index, and preoperative diabetes. Moreover, 1-, 5-, and 10-year survival of patients with preoperative RVD was significantly worse than patients without RVD (log-rank = 0.001).ConclusionsIn our population, RVD influenced both in-hospital and long-term results after heart transplant. For these reasons, it appears crucially important to optimize preoperative right ventricular function to improve these patients’ outcomes.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.     

Revision Surgery for Instability After Total Hip Arthroplasty: Does Timing Matter?

BackgroundInstability is a common reason for revision surgery after total hip arthroplasty (THA). Recent studies suggest that revisions performed in the early postoperative period are associated with higher complication rates. The purpose of this study is to assess the effect of timing of revision for instability on subsequent complication rates.MethodsThe Medicare Part A claims database was queried from 2010 to 2017 to identify revision THAs for instability. Patients were divided based on time between index and revision surgeries: <1, 1-2, 2-3, 3-6, 6-9, 9-12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics and comorbidities.ResultsOf 445,499 THAs identified, 9298 (2.1%) underwent revision for instability. Revision THA within 3 months had the highest rate of periprosthetic joint infection (PJI): 14.7% at <1 month, 12.7% at 1-2 months, and 10.6% at 2-3 months vs 6.9% at >12 months (P < .001). Adjusting for confounding factors, PJI risk remained elevated at earlier periods: <1 month (adjusted odds ratio [aOR]: 1.84, 95% confidence interval [CI]: 1.51-2.23, P < .001), 1-2 months (aOR: 1.45, 95% CI: 1.16-1.82, P = .001), 2-3 months (aOR: 1.35, 95% CI: 1.02-1.78, P = .036). However, revisions performed within 9 months of index surgery had lower rates of subsequent instability than revisions performed >12 months (aOR: 0.67-0.85, P < .050), which may be due to lower rates of acetabular revision and higher rates of head-liner exchange in this later group.ConclusionWhen dislocation occurs in the early postoperative period, delaying revision surgery beyond 3 months from the index procedure may be warranted to reduce risk of PJI.