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Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient =.70). Teaching hospitals were less likely to have satisfactory documentation for both TKA (P =.002) and THA (P =.029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals' TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness. [ABSTRACT FROM AUTHOR]

Background: Malnutrition and obesity are established predictors of complications following joint replacement surgery. However, the effect of obesity in the setting of albumin deficiency has not been explored in non-weight-bearing upper-extremity joint arthroplasty. Purpose: We sought to determine whether there is a synergistic effect between obesity and hypoalbuminemia among patients undergoing primary total shoulder arthroplasty (TSA) with respect to postoperative outcomes, including (1) mortality rates, (2) composite surgical complications, (3) length of hospitalization, and (4) hospital readmission. Methods: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database to find patients who underwent primary TSA from January 1, 2006, to December 31, 2019. We grouped these patients as obese (body mass index [BMI] ≥ 30 kg/m2) or nonobese (BMI = 18.5–29.9 kg/m2) and by serum albumin level (hypoalbuminemia < 3.5 mg/dL or normoalbuminemia ≥ 3.5 mg/dL). We gathered data on readmission and mortality rates, and NSQIP complications were organized into 3 composite variables: wound infection, systemic infection, and cardiac/pulmonary complication. For each outcome, multivariate logistic regression analysis evaluated its association with obesity and hypoalbuminemia, as well as with the interaction of BMI and albumin, while adjusting for covariates. Results: Of 12,881 patients, 51.8% were obese and 7.0% had hypoalbuminemia; 7.6% of obese patients had hypoalbuminemia versus 6.3% of those who were not obese. Patients with hypoalbuminemia had the longest hospital stays and the highest rates of mortality and systemic infection of all subgroups. Multivariate logistic regression analysis did not show higher complication rates due to obesity or evidence of additive interaction between hypoalbuminemia and obesity. Conclusion: Unlike previous reports in weight-bearing arthroplasty, in this retrospective study of a cohort of patients who underwent TSA, we did not observe greater complications due to obesity alone, nor did we find evidence of additive interaction between obesity and hypoalbuminemia. This distinction may be due to the non-weight-bearing nature of TSA, in which excessive BMI may be less relevant for postoperative healing. [ABSTRACT FROM AUTHOR]

Study Design: retrospective cohort study. Objectives: To test and compare 2 machine learning algorithms to define characteristics associated with candidates for ambulatory same day laminectomy surgery. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent single level laminectomy in 2017 and 2018. The main outcome was ambulatory same day discharge. Study variables of interest included demographic information, comorbidities, preoperative laboratory values, and intra-operative information. Two machine learning predictive modeling algorithms, artificial neural network (ANN) and random forest, were trained to predict same day discharge. The quality of models was evaluated with area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) measures. Results: Among 35,644 patients, 13,230 (37.1%) were discharged on the day of surgery. Both ANN and RF demonstrated a satisfactory model quality in terms of AUC (0.77 and 0.77), accuracy (0.69 and 0.70), sensitivity (0.83 and 0.58), specificity (0.55 and 0.80), PPV (0.77 and 0.69), and NPV (0.64 and 0.70). Both models highlighted several important predictive variables, including age, duration of operation, body mass index and preoperative laboratory values including, hematocrit, platelets, white blood cells, and alkaline phosphatase. Conclusion: Machine learning approaches provide a promising tool to identify candidates for ambulatory laminectomy surgery. Both machine learning algorithms highlighted the as yet unrecognized importance of preoperative laboratory testing on patient pathway design. [ABSTRACT FROM AUTHOR]

Background: With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. Purpose: We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. Methods: We retrospectively reviewed inpatient electronic medical record data (2016–2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Results: Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). Conclusions: This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery. [ABSTRACT FROM AUTHOR]

Background: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. Questions/Purpose: We sought to investigate the effect of these selection criteria on perioperative outcomes. Methods: In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998–2006) and those who underwent surgery after (2007–2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. Results: Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. Conclusion: After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes. [ABSTRACT FROM AUTHOR]

Background: The use of regional anesthesia (RA) in pediatric patients remains understudied, although evidence suggests benefits over general anesthesia. Questions/Purposes: We sought to identify factors associated with RA use in patients under the age of 21 years undergoing ambulatory orthopedic surgery. Methods: Patients under the age of 21 who underwent anterior cruciate ligament (ACL) repair or reconstruction, knee arthroscopy (KA), or shoulder arthroscopy (SA) were identified from the NY Statewide Planning and Research Cooperative System (SPARCS) database (2005–2015). Frequencies of RA use (defined by femoral nerve block, spinal, epidural, caudal, or brachial plexus anesthesia) were calculated. Multivariable regression analysis identified patient- and healthcare system–related factors associated with the use of RA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. Results: We identified 87,273 patients who underwent the procedures of interest (ACL n = 28,226; SA n = 18,155; KA n = 40,892). In our primary analysis, 14.4% (n = 1404) had RA as their primary anesthetic; this percentage increased for patients who had ACL or KA. When adjusting for covariates, Hispanic ethnicity (OR 0.78; CI 0.65–0.94) and Medicaid insurance (OR 0.75; CI 0.65–0.87) were associated with decreased odds for the provision of RA. Further, we identified increasing age (OR 1.10; CI 1.08–1.11), ACL versus SA (OR 1.91; CI 1.74–2.10), and sports injuries (OR 1.20; CI 1.10–1.31) as factors associated with increased odds of RA use. Conclusion: In this analysis, RA was used in a minority of patients under the age of 21 undergoing ambulatory orthopedic surgery. Older age was associated with increased use while Hispanic ethnicity and lower socioeconomic status were associated with lower use. [ABSTRACT FROM AUTHOR]

Background: There is a concern for higher rates of wound complications and a potentially increased periprosthetic joint infection (PJI) risk after total hip arthroplasty (THA) with the direct anterior approach (DAA) compared to the posterolateral approach (PLA). Our purpose was to compare PJI risk after THA with the DAA or the PLA and to identify risk factors for PJI after primary THA. Methods: Clinical characteristics of patients treated in our institution with primary DAA or PLA THA between 1/2010 and 12/2015 were retrospectively reviewed. The respective deep PJI rates were calculated. A logistic regression model was constructed to determine a potential difference in the PJI risk between the 2 groups, and risk factors for hip PJI in all patients. Results: During the period studied, there were 1,182 DAA THAs and 18,853 PLA THAs. The PJI rate was 0.25% for the DAA group and 0.31% for the PLA group (p = 1.0). The DAA was not associated with a significantly increased risk for PJI compared to the PLA. Compared to younger patients, older patients had lower PJI risk; patient discharge to home was also associated with lower PJI risk compared to other discharge disposition; longer length of stay was associated with higher PJI risk compared to shorter length of stay. Conclusion: The DAA is equally safe compared the PLA with respect to PJI risk. Younger age, discharge to facilities other than home and increased length of stay increase the risk for deep PJI after primary THA. [ABSTRACT FROM AUTHOR]

Elderly patients undergoing hip fracture surgery represent a myriad of perioperative challenges and risks. The arrival of the global pandemic of novel coronavirus disease 2019 (COVID-19) adds an unprecedented challenge to the management of hip fracture patients. We describe the unique experience and favorable outcome of a 100-year-old COVID-positive hip fracture patient that underwent spinal anesthesia for hemiarthroplasty and subsequent hydroxychloroquine (HCQ) therapy. Multiple factors of varying known benefit may have contributed to our outcome, including preoperative medical consultation and assessment, early surgical intervention, regional anesthesia with little to no sedation, early mobilization and HCQ therapy. [ABSTRACT FROM AUTHOR]

Background: Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients.Questions/Purposes: The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions?Methods: We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence.Results: A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation.Conclusion: Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines. [ABSTRACT FROM AUTHOR]

Background: While it is assumed that neuraxial analgesia and pain management may beneficially influence perioperative hemodynamics, few studies provided data quantifying such effects and none have assessed the potential contribution of the addition of a nerve block. Questions/Purposes: This clinical trial compared the visual analog scale (VAS) scores and measurement of arterial tone using augmentation index of patients who received combined spinal-epidural (CSE) only to patients who received both CSE and lumbar plexus block. Methods: After obtaining written consent, 92 patients undergoing total hip arthroplasty were randomized to receive either CSE or CSE with lumbar plexus block (LPB). Perioperative pain and arterial tone were measured using VAS scores and augmentation index (AI) respectively, at baseline and at various times postoperatively. Results: After the exclusion of 2 patients, 44 patients received CSE alone and 46 patients received CSE and LPB. Patient demographics and perioperative characteristics were similar in both groups. AI continuously decreased after placement of a CSE with or without LBP, beyond full resolution of neuraxial and peripheral blockade. Although the LPB group demonstrated a statistically significant reduction of VAS pain scores in the postanesthesia care unit (PACU; P<0.05), overall, the addition of a LPB did not significantly reduce the AI when compared to the control group. Conclusion: The addition of a LPB provided better pain control in the PACU but did not reduce the AI, compared to the control group. We conclude that the addition of a LPB may have limited ability to affect arterial tone in the presence of a continuous infusion of epidural analgesics. In summary, the addition of a LPB in patients undergoing total hip arthroplasty is clinically effective and provided better pain control, especially in the immediate postoperative period. The continuous decrease on the AI in both groups beyond the full resolution of the neuroaxial and LPB will require further studies. [ABSTRACT FROM AUTHOR]

Background: Data on the utilization of critical care services (CCSs) among patients who underwent spine fusion are rare. Given the increasing popularity of this procedure, information regarding demographics and risk factors for the use of these advanced services is needed in order to appropriately allocate resources, educate clinical staff, and identify targets for future research. Methods: We analyzed hospital discharge data of patients who underwent lumbar spine fusion in approximately 400 US hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics for those requiring CCS were compared to those who did not. Outcomes such as mortality, complications, disposition status, and hospital charges were compared among groups and risk factors for the utilization of CCS identified. Results: A total of 95 434 entries of patients who underwent posterior lumbar spine fusion surgery between 2006 and 2010 were identified. Approximately 10% of the patients required CCS. On average, patients requiring CCS were older and had a higher comorbidity burden, developed more complications, had longer hospital stays and higher costs, and were less likely to be discharged home compared to non-CCS patients. Risk factors with increased odds for requiring CCS included advanced age, increasing comorbidity burden, increasing surgical invasiveness, and presence of postoperative complications, especially pulmonary. Conclusions: Approximately, 10% of the patients undergoing lumbar spine surgery require CCS. Utilizing the present data, critical care physicians and administrators can identify patients at risk, educate clinical staff, identify targets for intervention, and allocate resources to meet the needs of this particular patient population. [ABSTRACT FROM AUTHOR]