Total Joint Arthroplasty Surgery: Does Day of Surgery Matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.     

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.     

Does Body Mass Index Affect Outcomes of Ambulatory Knee and Shoulder Surgery?

Purpose

Obesity is highly prevalent among patients with knee and shoulder injuries and is associated with greater odds of surgical treatment for these injuries. The purpose of this systematic review was to summarize the literature that has examined the association between body mass index (BMI) and outcomes of ambulatory knee and shoulder surgery.

Methods

A literature search of PubMed and Medline was conducted up to December 2013. Studies that examined the association between BMI and outcomes after ambulatory knee and shoulder surgery (arthroscopy, repairs, and reconstructions) were included. Outcomes included postoperative functional scores, clinical scores, and complications.

Results

Eighteen studies were included in this review; 13 involved knee surgery and 5 involved shoulder surgery. Seven knee studies and 2 shoulder studies found increased BMI to be associated with worse postoperative outcomes, whereas the remaining 9 studies did not find an association. Increased BMI was associated with worse clinical scores and less patient satisfaction after arthroscopic meniscectomy or debridement, and with worse clinical scores and lower activity levels after anterior cruciate ligament (ACL) reconstruction. It was also associated with worse clinical scores and a longer hospital stay after rotator cuff repair and with longer time to return to work after subacromial decompression. Six studies examined the association between BMI and complications, but all reported null findings.

Conclusions

There is a lack of consensus in the literature regarding the association between BMI and ambulatory knee and shoulder surgery. Several factors may have contributed to contradictory findings, including variation in measuring and classifying anthropometry, postoperative outcomes, and follow-up time.

Level of Evidence

Level IV, systematic review of Level I, III, and IV studies.     

Does Time to Surgery Affect Outcomes for Periprosthetic Femur Fractures?

Background

Periprosthetic femur fractures around total hip (THA) and total knee (TKA) arthroplasties are difficult complications to manage. With native hip fractures, delay to fixation has been correlated with an increase in postoperative mortality. The effect of time to definitive fixation of periprosthetic femur fractures around THA and TKA is not well established. The aim of our study is to evaluate the effect of time to definitive fixation on postoperative length of stay and mortality for patients with periprosthetic femur fractures around THA and TKA.

Does Chemotherapy Prior to Emergency Surgery Affect Patient Outcomes? Examination of 1912 Patients

Background  

Data regarding preoperative chemotherapy as a risk to surgical outcomes are limited. This study examines morbidity and mortality among patients necessitating emergent surgical procedures ≤30 days after chemotherapy.     

Outcomes in Oncologic Surgery: Does Volume Make a Difference?

Commonly performed elective surgical procedures on the alimentary tract are carried out with low morbidity and low mortality in most hospitals in the United States. There are some procedures on the alimentary tract that are performed with a relatively low frequency and are associated with higher mortality. Volume is a surrogate marker associated with improved outcome, with relative differences being dependent on the complexity of the procedure and the frequency with which it is done. Both surgeon and institutional volume matters, but it seems that improved operative mortality can be reached with lower surgeon volume in high-volume institutions. It appears that volume can be substituted in part for by specialization and training, with improved outcomes based on specialist credentials and fellowship training.     

Does Obesity Affect the Surgical Outcome and Complication Rates of Spinal Surgery? A Meta-analysis

Background

As obesity becomes more prevalent, it becomes more common among patients considering orthopaedic surgery, including spinal surgery. However, there is some controversy regarding whether obesity is associated with complications, failed reconstructions, or reoperations after spinal surgery.

Questions/purposes

We wished to determine, in patients undergoing spine surgery, whether obesity is associated with (1) surgical site infection, (2) mortality and the need for revision surgery after spinal surgery, and (3) increased surgical time and blood loss.

Methods

A systematic literature search was performed to collect comparative or controlled studies that evaluated the influence of obesity on the surgical and postoperative outcomes of spinal surgery. Two reviewers independently selected trials, extracted data, and assessed the methodologic quality and quality of evidence. Pooled odds ratios (OR) and mean differences (MD) with 95% CIs were calculated using the fixed-effects model or random-effects model. Data were analyzed using RevMan 5.1. MOOSE criteria were used to ensure this project’s validity. Thirty-two studies involving 97,326 patients eventually were included.

Results

Surgical site infection (OR, 2.33; 95% CI, 1.94–2.79), venous thromboembolism (OR, 3.15; 95% CI, 1.92–5.17), mortality (OR, 2.6; 95% CI, 1.50–4.49), revision rate (OR, 1.43; 95% CI, 1.05–1.93) operating time (OR, 14.55; 95% CI, 10.03–19.07), and blood loss (MD, 28.89; 95% CI, 14.20–43.58), were all significantly increased in the obese group.

Conclusion

Obesity seemed to be associated with higher risk of surgical site infection and venous thromboembolism, more blood loss, and longer surgical time. Future prospective studies are needed to confirm the relationship between obesity and the outcome of spinal surgery.

     

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.     

Clinical Outcomes and Survivorship of Lateral Unicompartmental Knee Arthroplasty: Does Surgical Approach Matter?

Background

Lateral unicompartmental knee arthroplasty (UKA) has been shown to be an effective procedure to treat isolated lateral compartment osteoarthritis with excellent long-term survivorship. Whether a medial parapatellar approach or a lateral parapatellar approach is superior in lateral UKA is unknown. The purpose of this study was to determine if there is a difference in intermediate-term clinical outcomes in patients undergoing lateral UKA through a lateral vs medial parapatellar approach.

Aseptic Loosening Rates in Distal Femoral Endoprostheses: Does Stem Size Matter?

Background  

Long-term survival of distal femoral endoprosthetic replacements is largely affected by aseptic loosening. It is unclear whether and to what degree surgical technique and component selection influence the risk of loosening.     

Does Limb-salvage Surgery Offer Patients Better Quality of Life and Functional Capacity than Amputation?

Introduction  

Patients with aggressive lower extremity musculoskeletal tumors may be candidates for either above-knee amputation or limb-salvage surgery. However, the subjective and objective benefits of limb-salvage surgery compared with amputation are not fully clear.     

Neoadjuvant Long-Course Chemoradiotherapy for Rectal Cancer: Does Time to Surgery Matter?

The objective of this paper was to evaluate whether delaying surgery following long-course chemoradiotherapy for rectal cancer correlates with pathologic complete response. Pre-operative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer. Optimal timing of surgery following CRT is still not clearly defined. All patients with a diagnosis of rectal cancer who had undergone long-course CRT prior to surgery between January 2008 and December 2011 were included. Statistical analysis was performed using Stata 11. Fifty-nine patients received long-course CRT prior to surgery in the selected period. Twenty-seven percent (16/59) of patients showed a complete histopathologic response and 59.3% (35/59) of patients had tumor down-staging from radiologically-assessed node positive to histologically-proven node negative disease. There was no statistically significant delay to surgery after completion of CRT in the 16 patients with complete response (CR) compared with the rest of the group [IR: incomplete response; CR group median: 74.5 days (IQR: 70–87.5) and IR group median: 72 days (IQR: 57–83), P = 0.470]. Although no statistically significant predictors of either complete response or tumor nodal status down-staging were identified in logistic regression analyses, a trend toward complete response was seen with longer delay to surgery following completion of long-course CRT.Key words: Interval to surgery, Rectal cancer, Long-course chemoradiotherapyIn the multimodal management of rectal cancer, surgical resection remains the mainstay of treatment. Total mesorectal excision (TME) has become the standard operative technique resulting in reduced rates of local recurrence compared with previous conventional surgery.^1,2 Apart from surgery, neoadjuvant radiotherapy is employed in resectable rectal cancer to reduce the risk of local recurrence, and in locally-advanced rectal cancer, to downsize the tumor and facilitate subsequent successful R0 resection or sphincter-preserving surgery.^3,4 Two meta-analyses have reported that preoperative radiotherapy plus surgery when compared with surgery alone significantly reduced the 5-year overall mortality rate, cancer-related mortality rate, and local recurrence rates in resectable rectal cancer.^5,6Preoperative radiotherapy is usually given either as a short- or long-course treatment schedule. Short-course radiotherapy typically involves 25 Gy in 5 fractions given in 1 week,⁷ whereas long-course treatment consists of 45 Gy given in 25 fractions over 5 weeks as standard⁸ with concomitant chemotherapy as a radiosensitizer. The Swedish Rectal Cancer Trial showed statistically significant reduction in the local recurrence rates and increase in the overall survival rates at a median follow-up of 13 years in the group receiving short-course preoperative radiotherapy compared with surgery alone.⁷ The Dutch trial also confirmed that short-course radiotherapy reduced the risk of local recurrence in patients who underwent a standardized TME.⁹ Although no chemotherapy was considered in the above studies, the EORTC Radiotherapy Group trial concluded that long-course preoperative radiotherapy with chemotherapy given either preoperatively or postoperatively conferred significant benefit in terms of local control, but did not improve survival.⁸ Finally, the German Rectal Cancer Study Group showed that preoperative chemoradiotherapy (CRT) compared with postoperative CRT improved local recurrence rates and was associated with reduced toxicity.¹⁰A 6 to 8 week interval to surgery from completion of neoadjuvant CRT has become standard practice since the results of the Lyons R90-01 study were published.¹¹ In this trial, a longer interval of 6 weeks when compared to 2 weeks post-CRT was associated with increased tumor down-staging.¹¹ However, it is not clear whether a yet longer delay before surgery might result in further tumor down-staging or in higher rates of pathologic complete response. The aim of our retrospective study was to evaluate whether a longer interval between completion of long-course CRT and surgery for locally-advanced rectal cancer might maximize the effectiveness of CRT in achieving complete response.     

Do Patient Expectations of Spinal Surgery Relate to Functional Outcome?

It is important for surgeons to understand patients' expectations for surgery. We asked whether patient factors and preoperative functional outcome scores reflect the degree of expectations patients have for posterior spinal surgery. Second, we asked whether patients' expectations for surgery predict improvements in functional outcome scores after surgery. We prospectively enrolled 155 consecutive surgical patients with greater than 90% followup. Patients' expectations were evaluated preoperatively along with SF-36 and Oswestry disability questionnaires. Postoperatively (6 months for decompression; 1 year for fusions), we quantified patient-derived satisfaction regarding whether expectations were met and by patient-derived functional outcome scores. In patients undergoing decompression, gender, SF-36 general health domain, and SF-36 physical component score predicted patients with high expectations for surgery. Patients with high expectations also reported greater postoperative improvements in SF-36 role physical domain scores after surgery. Expectations for surgery were met in 81% of patients. In a subset of patients (21 of 143), expectations were not met. These patients reported lower mean preoperative SF-36 general health, vitality, and mean mental component scores.