Increased Operative Time Impacts Rates of Short-Term Complications After Unicompartmental Knee Arthroplasty

BackgroundPrevious evidence has demonstrated an exacerbating effect of increased operative time on short-term complications in total joint arthroplasty. While the same relationship may be expected for unicompartmental knee arthroplasty (UKA), supporting evidence remains sparse. The purpose of this study is to determine the impact of operative time on short-term complication rates after UKA and determine a critical threshold in operative times after which complications may increase.MethodsThe American College of Surgeons National Surgical Quality Improvement Project was queried from 2007 to 2018 to identify 11,633 UKA procedures that were included in the final analysis. The effect of operative time on complications within 30 days was evaluated using multivariate logistic regression models. Receiver operating characteristics curves and spline regression models were used to identify critical thresholds in operative time that increase the likelihood of short-term complications.ResultsLonger operative times (in minutes) were associated with higher rates of surgical site infection (90.4 ± 26.7 vs 84.8 ± 25.5, P = .003), blood transfusions (94.9 ± 28.6 vs 84.9 ± 25.5, P = .007), as well as reoperation rates (90.8 ± 27.9 vs 84.9 ± 25.5, P = .01), extended hospital length of stay (93.4 ± 29.8 vs 84.5 ± 25.2, P < .001), and mortality (110.4 ± 35.5 vs 84.9 ± 25.5, P = .008). Following multivariate logistic regression, operative time was found to independently predict increased surgical site infection, blood transfusion, myocardial infarction, extended length of stay, and mortality (odds ratio: 1.09 – 1.45, CI: 1.01 – 1.91, all P values <0.02). Receiver operating characteristics curves found an increase in mortality risk during the 30-day postoperative period after 88.5 minutes of operative time, a finding supported by spline regression plots.ConclusionThe present study found a positive correlation between increased operative times and short-term postoperative complication rates after UKA. Despite a statistically significant association with increasing operative time, odds ratios of reported complications are relatively low.     

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BackgroundDexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA.MethodsA retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone.ResultsNo differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001).ConclusionPerioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.     

Early Identification of Patient Satisfaction Two Years After Total Knee Arthroplasty

BackgroundThere are numerous reports of poor satisfaction after total knee arthroplasty (TKA), yet there is little known about when to use evidence-based models of care to improve patient outcomes.ObjectiveThis study aimed to characterize longitudinal changes in patient-reported satisfaction after TKA and to identify factors for early identification of poor satisfaction.MethodsFor a cohort of primary TKA surgeries (n = 86), patient-reported outcomes were captured one week before TKA and 6 weeks, 12 weeks, 6 months, and 1 and 2 years after TKA. “Satisfied” versus “not fully satisfied” patients were defined using a binary response (≥90 vs <90) from a 100-point scale. Wilcoxon signed-rank tests identified changes in satisfaction between follow-up times, and longitudinal analyses examined demographic and questionnaire factors associated with satisfaction.ResultsImprovements in satisfaction occurred within the first 6 months after TKA (P ≤ 0.01). Preoperative patient-reported outcome measures alone were not predictive of satisfaction. Key factors that improved longitudinal satisfaction included higher Oxford Knee Scores (odds ratio (OR) = 2.1, P < .001), general health (EQ-VAS, OR = 1.3, P = .03), and less visual analog scale pain (VAS; OR = 1.7, P < .001). Differences in these factors between satisfied and not fully satisfied patients were identified as early as 6 weeks after surgery.ConclusionVisibly different satisfaction profiles were captured among satisfied and not fully satisfied patient responses, with differences in patient-perceived joint function, general health, and pain severity occurring as early as 6 weeks after surgery. This study provides metrics to support early identification of patients at risk of poor TKA satisfaction, enabling clinicians to apply timely targeted treatment and support interventions, with the aim of improving patient outcomes.     

Is Patient Satisfaction After Total Knee Arthroplasty Predictable Using Patient Characteristics and Preoperative Patient-Reported Outcomes?

BackgroundDissatisfaction after total knee arthroplasty (TKA) remains a difficult problem. Patient characteristics and preoperative patient-reported outcomes (PROs) are potential predictors of satisfaction one year after TKA. Being able to predict the outcome preoperatively might reduce the number of less satisfied patients.MethodsA retrospective cohort study on prospectively collected data of 1239 primary TKA patients (ASA I-II, BMI <35) was performed. Primary outcome was degree of patient satisfaction one year after TKA (Numeric Rating Scale (NRS) 0-10). Secondary outcomes were degree of patient satisfaction six months and two years after TKA and being dissatisfied (NRS 0-6) or satisfied (NRS 7-10) at all three time points. Multivariate linear and binary logistic regression analyses were executed with patient characteristics and preoperative PROs as potential predictors.ResultsOne year after TKA, median NRS satisfaction score was 9.0 (8.0-10.0) and 1117 (90.2%) patients were satisfied. BMI, degree of medial cartilage damage, previous knee surgery, Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form score, EQ VAS score, and anxiety were identified as predictors of the degree of patient satisfaction (P = .000, R² = 0.027). Models on secondary outcomes reported R² of 1.7%-7.1% (P < .05). All models showed bad agreement between observed and predicted values for lower NRS satisfaction scores and being dissatisfied.ConclusionThe degree of patient satisfaction and the chance of being dissatisfied or satisfied six months, one, and two years after TKA are predictable by patient characteristics and preoperative PROs but not at a reliability level that is clinically useful.     

Risks and Complications After Arthroplasty for Pathological or Impending Pathological Fracture of the Hip

BackgroundTreatment options for metastatic osseous lesions of the proximal femur include hemiarthroplasty (HA) or total hip arthroplasty (THA) depending on lesion characteristics and patient demographics. Studies assessing short-term outcomes after HA/THA in this patient population are limited. Therefore, the purpose of this present study was to identify short-term rates of morbidity and mortality after HA/THA for pathological proximal femur fractures, as well as readmission and reoperation rates and reasons.MethodsThis study utilized a large, prospectively collected registry to identify patients who underwent HA/THA between 2011 and 2018. Patients were stratified by indication for surgery, including pathological fracture, nonpathological fracture, and osteoarthritis. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis.ResultsIn total, 883 patients undergoing HA/THA for a pathological fracture were identified. Relative to an osteoarthritis cohort, these patients tended to be older, had a lower body mass index, and had significantly more preoperative comorbidities. These patients had high rates of total complications (13.93%), including thirty-day mortality (3.29%), unplanned return to the operating room (4.98%), and pulmonary complications (3.85%). Patients with pathological fracture had a longer operative duration relative to osteoarthritis and nonpathological cohorts (+27 and +25 minutes, respectively), despite having high rates of HAs performed.ConclusionPatients undergoing hip arthroplasty for pathologic proximal femur fracture have increased morbidity and mortality relative to an osteoarthritis cohort. However, patients with a pathological fracture have similar rates of morbidity and mortality when compared with a nonpathological fracture cohort, but did experience higher rates of perioperative blood transfusion and unplanned readmissions.Level of EvidenceIII.     

Can Met Expectations Moderate the Relationship Between Pain/Function and Satisfaction in Total Knee Arthroplasty?

BackgroundApproximately 20% of patients are dissatisfied with their total knee arthroplasty (TKA) at 1-year post-surgery. Met expectations have been found by some to significantly predict satisfaction. The role of met expectations in determining patient satisfaction has not been exhaustively explored. The primary aim of this study is to evaluate if met expectations moderate the relationship between pain and function variables and satisfaction.MethodsPatients who underwent primary TKA for osteoarthritis were included in the study (n = 304). Patient-reported outcomes at pre-surgery and 1-year post-surgery were collected. The Knee Society Score (KSS) satisfaction subscale was used as the dependent variable. Candidate independent variables included the following: demographics, KSS, Knee injury and Osteoarthritis Outcome Score (KOOS), 12-Item Short Form Health Survey (SF-12), Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Self-Administered Comorbidity Questionnaire, and University of California Los Angeles activity score. Separate linear regression models were created to test interactions for KSS met expectations with pain and KSS met expectations with function.ResultsSignificant predictors of satisfaction were KSS symptoms (pain), KOOS activities of daily living (function), KSS met expectations, KOOS pre-surgery activities of daily living, body mass index, and SF-12 general health. A significant interaction between met expectations and pain was found (P = .043) and the met expectations and function interaction approached significance (P = .086). For both interactions, as met expectations increased, pain and function predicted satisfaction less strongly.ConclusionMet expectations were found to moderate the relationship between pain and satisfaction. There may be more value in improving pain for patients with low met expectations.Level of evidenceLevel IV.     

Utility and Prognostic Ability of a Diagnostic Injection Before Revision Total Knee Arthroplasty

BackgroundDiagnostic injections are commonly utilized in the workup of painful total knee arthroplasties (TKA), particularly when the diagnosis remains unclear. However, current literature provides limited evidence regarding the utility and prognostic capability of anesthetic injections in this scenario. This study sought to establish the role of diagnostic injections in predicting successful revision TKA.MethodsA retrospective review was conducted on 144 consecutive aseptic revision TKAs receiving diagnostic anesthetic injections. Instability (57.6%) and aseptic loosening (33.3%) comprised most revision etiologies. Patient-reported percentage pain relief after the injection was statistically correlated with KOOS JR, Knee Society Score, UCLA Activity Level, and satisfaction scores.ResultsAbout 74.3% (107/144) of revision TKAs reported >50% pain relief after injection. There were no differences in pain relief based on revision indication (P = .841). Improvement from preoperative activity level was greater in the >50% pain relief group (P = .024). Four-month patient satisfaction did not differ between patients who reported >50% and ≤50% pain relief (67% vs. 66%, P = .130). About 64% of patients who reported >50% pain relief were satisfied at minimum 1-year follow-up, compared with only 47% of those who reported ≤50% pain relief after diagnostic injection (P < .001).ConclusionStudy results show that patients reporting >50% pain relief after diagnostic injection have improvements in activity level and maintain greater satisfaction at minimum 1-year than those reporting ≤50% pain relief. Expectations for improvement after revision TKA should be tempered if diagnostic anesthetic injection yields minimal subjective pain relief.     

Total Hip Arthroplasty in Patients With Osteoarthritis Associated With Legg-Calve-Perthes Disease: Perioperative Complications and Patient-Reported Outcomes

BackgroundComplications and patient-reported outcomes (PROs) of total hip arthroplasty (THA) in patients with Legg-Calve-Perthes disease (LCPD) have demonstrated variable results. The purpose of this study was to use a validated grading scheme to analyze complications associated with THA in patients with residual LCPD deformities. Second, we report PROs and intermediate-term survivorship in this patient population.MethodsA retrospective, single-center review was performed on 61 hips in 61 patients who underwent THA for residual Perthes disease. Average patient age was 42 years and 26% of hips had previous surgery. Complications were determined and categorized using a validated grading scheme that included five grades based on the treatment required to manage the complication and on persistent disability. PROs were compared from preoperative to most recent follow-up time points.ResultsMajor complications (grade III) occurred in three patients (5%) which each required a second surgical intervention. The most common minor grade I or II complications (11.5%) were asymptomatic heterotopic ossification (3.3%). Patients were lengthened on the surgical side an average of 1.4 cm with no nerve palsies. All patient PROs improved from preoperative to postoperative time points with the modified Harris Hip Score improving from 46.9 preoperatively to 85.4 postoperatively (P < .01). Patients free from revision for any reason at final follow-up (5.6 years; range 2-13 years) was 98.4% with one patient needing a revision of their femoral component.ConclusionsTHA for the sequelae of the LCPD has an acceptable complication rate and provides excellent patient reported outcomes at mid-term follow-up.     

Risk factors and outcomes of cardiovascular disease readmission within the first year after dialysis in peritoneal dialysis patients

BackgroundIn the first year of dialysis, patients are vulnerable to cardiovascular disease (CVD) hospitalization, but knowledge regarding the risk factors and long-term outcomes of cardiovascular readmission within the first year after dialysis in incident continuous ambulatory peritoneal dialysis (CAPD) patients is limited.MethodsThis retrospective cohort study was conducted in incident CAPD patients. The demographic characteristics, laboratory parameters, and CVD readmission were collected and analyzed. The primary outcome was all-cause mortality, and the secondary outcomes included CVD mortality, infection-related mortality and technique failure. A logistic regression was used to identify the risk factors associated with CVD readmission within the first year after dialysis. Cox proportional hazards models were used to evaluate the association between CVD readmission and the outcomes.ResultsIn total, 1589 peritoneal dialysis (PD) patients were included in this study, of whom 120 (7.6%) patients had at least one episode of CVD readmission within the first year after dialysis initiation. Advanced age, CVD history, and a lower level of serum albumin were independently associated with CVD readmission. CVD readmission within the first year after dialysis was significantly associated with all-cause (HR 2.66, 95%CI 1.91–3.70, p < 0.001) and CVD (HR 3.42, 95%CI 2.20–5.31, p < 0.001) mortality, but not infection-related mortality or technique failure, after adjusting for confounders.ConclusionsOur findings suggest that an advanced age, a history of CVD, and a lower level of serum albumin were independently associated with CVD readmission. Moreover, CVD readmission was associated with all-cause and cardiovascular mortality in incident CAPD patients.     

Cardiac function in adolescents and young adults with 22q11.2 deletion syndrome without congenital heart disease

BackgroundDiagnosis and treatment of 22q11.2 deletion syndrome (22q11.2DS) have led to improved life expectancy and achievement of adulthood. Limited data on long-term outcomes reported an increased risk of premature death for cardiovascular causes, even without congenital heart disease (CHD). The aim of this study was to assess the cardiac function in adolescents and young adults with 22q11.2DS without CHDs.MethodsA total of 32 patients (20M, 12F; mean age 26.00 ± 8.08 years) and a healthy control group underwent transthoracic echocardiography, including Tissue Doppler Imaging (TDI) and 2-dimensional Speckle Tracking Echocardiography (2D-STE).ResultsCompared to controls, 22q11.2DS patients showed a significant increase of the left ventricle (LV) diastolic and systolic diameters (p = 0.029 and p = 0.035 respectively), interventricular septum thickness (p = 0.005), LV mass index (p < 0.001) and aortic root size (p < 0.001). 2D-STE analysis revealed a significant reduction of LV global longitudinal strain (p < 0.001) in 22q11.2DS than controls. Moreover, several LV diastolic parameters were significantly different between groups.ConclusionsOur results suggest that an echocardiographic follow-up in 22q11.2DS patients without CHDs can help to identify subclinical impairment of the LV and evaluate a potential progression of aortic root dilation over time, improving outcomes, reducing long-term complications and allowing for a better prognosis.