Search

Purpose: We sought to characterize trends in demographics, comorbidities, and postoperative complications among patients undergoing primary and revision cervical disc replacement (pCDR/rCDR) procedures. Methods: In this retrospective database study, the Premier Healthcare database was queried from 2006 to 2019. Annual proportions or medians were calculated for patient and hospital characteristics, comorbidities, and postoperative complications associated with CDR surgery. Trends were assessed using linear regression analyses with year of service as the sole predictor. Results: A total of 16,178 pCDR and 758 rCDR cases were identified, with a median (IQR) age of 46 (39; 53) and 51 (43; 60) years among patients, respectively. The annual number of both procedures increased between 2006 and 2019, from 135 to 2220 for pCDR (p < 0.001), and from 17 to 49 for rCDR procedures (p < 0.001), with radiculopathy being the main indication for surgery in both groups. Mechanical failure was identified as a major indication for rCDR procedures with an increase over time (p = 0.002). Baseline patient comorbidity burden (p = 0.045) and complication rates (p < 0.001) showed an increase. For both procedures, an increase in outpatient surgeries and procedures performed in rural hospitals was seen (pCDR: p = 0.045; p = 0.006; rCDR: p = 0.028; p = 0.034). Conclusion: PCDR and rCDR procedures significantly increased from 2006 to 2019. At the same time, comorbidity burden and complication rates increased, while procedures were more often performed in an outpatient and rural setting. The identification of these trends can help guide future practice and lead to further areas of research. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) protocols have been shown to benefit recovery after several operations. However, large-scale data on the association between the level of ERAS use and perioperative complications are scarce, particularly in surgeries with increasing ERAS uptake, including total hip (THA) and knee arthroplasty (TKA). Using US national data, we examined the relationship between the number of ERAS components implemented ('level') and perioperative outcomes.Methods: After ethics approval, we included 1 540 462 elective THA/TKA procedures (2006-2016, as recorded in the Premier Healthcare claims database) in this retrospective cohort study. Main outcomes were any complication, cardiopulmonary complications, mortality, blood transfusions, and length of stay. Eight commonly used ERAS components were included. Mixed-effects models measured associations between ERAS level and outcomes, with odds ratios (OR) and confidence intervals (CI) reported.Results: ERAS use increased over time; overall, 21.6% (n=324 437), 62.7% (n=965 953), and 18.0% (n=250 072) of cases were classified as 'High', 'Medium', or 'Low' ERAS. 'High ERAS', 'Medium ERAS', and 'Low ERAS' level of use were defined as such if they received either >6, 5-6, or <5 ERAS components, respectively. After adjustment for relevant covariates, higher levels of ERAS use were associated with incremental reductions in 'any complication': 'Medium' vs 'Low' (OR=0.84; CI, 0.82-0.86) and 'High' vs 'Low' (OR=0.71; CI, 0.68-0.74). Similar patterns were found for the other study outcomes. Individual ERAS components with the strongest effect estimates were early physical therapy, avoidance of a urinary catheter, and tranexamic acid administration.Conclusions: ERAS components were used more frequently over time, and the level of utilisation was independently associated with incrementally improved complication odds and reduced length of stay during the primary admission. Possible indication bias limits the certainty of these findings. [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]

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties.Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported.Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95).Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings. [ABSTRACT FROM AUTHOR]

Background: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.Methods: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.Results: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.Conclusions: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.Recommendation: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.Trial Registry Number: PROSPERO CRD42018099935. [ABSTRACT FROM AUTHOR]

Background: Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.Methods: National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported.Results: Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively.Conclusions: Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality. [ABSTRACT FROM AUTHOR]

The article offers information about the Enhanced Recovery After Surgery Society (ERAS) guidelines for hip and knee replacement. It mentions the evaluation of the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. It discusses the perioperative care in hip and knee replacement.

Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.Conclusions: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols. [ABSTRACT FROM AUTHOR]

The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest. Although mainly neuraxial vs general anesthesia has been addressed, population-level data on the impact of peripheral nerve blocks (PNBs) are still lacking. Therefore, we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties (total hip arthroplasty [THA]/total knee arthroplasty [TKA]) from the national Premier Perspective database (2006-2013). Multilevel multivariable logistic regression models measured associations between PNB use and outcomes. Complications included cardiac, pulmonary, gastrointestinal and renal complications, cerebrovascular events, infections, wound complications, thromboembolic complications, inpatient falls, and mortality. Resource utilization variables included blood transfusions, intensive care unit admissions, opioid consumption, cost, and length of stay. Overall, 12.5% of patients received a PNB, with an increase over time particularly among TKAs. Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA. Notable beneficial effects were seen for wound complications (odds ratio 0.60 [95% confidence interval, 0.49-0.74]) among THA recipients and pulmonary complications (odds ratio 0.83 [95% confidence interval, 0.72-0.94]) in patients with TKA. Peripheral nerve block use was significantly (P < 0.0001) associated with a -16.2% and -12.7% reduction in opioid consumption for patients with THA and TKA, respectively. In conclusion, our results indicate that PNBs might be associated with superior perioperative population-level outcomes. In light of the inability to establish a causal relationship and the presence of residual confounding, we strongly advocate for further prospective investigation, ideally in multicenter, randomized trials, to establish the potential impact of PNBs on outcomes on a population level. [ABSTRACT FROM AUTHOR]

Background: Differences in health care represent a major health policy issue. Despite increasing evidence on the mediating role of anesthesia type used for surgery on perioperative outcome, there is a lack of data on potential care differences in this field. The authors aimed to determine whether anesthesia practice (use of neuraxial anesthesia [NA] or peripheral nerve block [PNB]) differs by patient and hospital factors.Methods: The authors extracted data on n = 1,062,152 hip and knee arthroplasty procedures from the Premier Perspective database (2006 to 2013). Multilevel multivariable logistic regression models measured associations (odds ratios [ORs] and 95% CIs) between patient/hospital factors and NA or PNB use.Results: Of all patients, 22.2% (n = 236,083) received NA and 17.9% (n = 189,732) received PNB. Lower adjusted odds for receiving NA were seen for black patients (OR, 0.88; 95% CI, 0.86 to 0.91) and those on Medicaid (OR, 0.78; 95% CI, 0.74 to 0.82) or without insurance (OR, 0.89; 95% CI, 0.81 to 0.98). Furthermore, teaching hospitals (compared with nonteaching hospitals) had lower adjusted odds for NA utilization (OR, 0.35; 95% CI, 0.14 to 0.89). Although generally similar patterns were seen for PNB utilization, the main difference was that particularly Hispanic patients were less likely to receive PNB compared with white patients (OR, 0.60; 95% CI, 0.56 to 0.65). Sensitivity analyses generally validated our results.Conclusions: Significant differences exist in the provision of regional anesthetic care with factors such as race and insurance type being important determinants of anesthetic practice. Further and in-depth research is needed to fully assess the background of these differences. [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]

BACKGROUND: Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk in total knee arthroplasty patients. METHODS: The authors selected total knee arthroplasty patients from the national Premier Perspective database (Premier Inc., Charlotte, NC; 2006-2010; n = 191,570, >400 acute care hospitals). The primary outcome was IF. Patient- and healthcare system-related characteristics, anesthesia technique, and presence of PNB were determined for IF and non-IF patients. Independent risk factors for IFs were determined by using conventional and multilevel logistic regression. RESULTS: Overall, IF incidence was 1.6% (n = 3,042). Distribution of anesthesia technique was 10.9% neuraxial, 12.9% combined neuraxial/general, and 76.2% general anesthesia. PNB was used in 12.1%. Patients suffering IFs were older (average age, 68.9 vs. 66.3 yr), had higher comorbidity burden (average Deyo index, 0.77 vs. 0.66), and had more major complications, including 30-day mortality (0.8 vs. 0.1%; all P < 0.001). Use of neuraxial anesthesia (IF incidence, 1.3%; n = 280) had lower adjusted odds of IF compared with adjusted odds of IF with the use of general anesthesia alone (IF incidence, 1.6%; n = 2,393): odds ratio, 0.70 (95% CI, 0.56-0.87). PNB was not significantly associated with IF (odds ratio, 0.85 [CI, 0.71-1.03]). CONCLUSIONS: This study identifies several risk factors for IF in total knee arthroplasty patients. Contrary to common concerns, no association was found between PNB and IF. Further studies should determine the role of anesthesia practices in the context of fall-prevention programs. [ABSTRACT FROM AUTHOR]

Background: The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes.Methods: Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial-general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes.Results: Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial-general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial-general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08-3.1, P = 0.02; OR of 1.70, 95% CI 1.06-2.74, P = 0.02, respectively).Conclusions: The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings. [ABSTRACT FROM AUTHOR]

Study Objective: To monitor the pulmonary hemodynamics of patients undergoing bilateral total knee arthroplasty (BTKA) intraoperatively and up to 24 hours following surgery. Design: Prospective observational study. Setting: University-affiliated teaching hospital. Patients: 30 ASA physical status 2 and 3 patients scheduled for single-stage, cemented BTKA during epidural anesthesia. Interventions: Pulmonary artery catheters were in all patients. Measurements: Systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), the ratio of PVR to SVR at baseline, at the beginning of surgery, and after each knee implantation were recorded and compared with measurements taken one day postoperatively (POD 1). Main Results: On POD 1, PVR/SVR was increased by 30% compared with baseline (P < 0.0001) and by 20% versus the end of surgery (P < 0.0001). Systemic vascular resistance decreased during surgery and was significantly lower than baseline at 24 hours after surgery (P < 0.0001). No significant change in PVR was noted during surgery. Conclusion: The PVR/SVR ratio on the day following BTKA was increased. This change may represent the different effects of inflammatory perioperative stresses on the pulmonary and systemic vasculature. Published by Elsevier Inc. [ABSTRACT FROM AUTHOR]

The perioperative mortality of total knee and hip arthroplasties (TKA, THA) remains a major concern among health care providers and their patients. The increase in utilization of TKA and THA makes it imperative to be aware of factors that are associated with this unfortunate event. Therefore we analyzed the Nationwide Inpatient Sample data from 1998 to 2008 and compared admissions with perioperative mortality to those that survived their hospitalization. An estimated total of 4,438,213 TKA and 2,182,121 THA procedures were performed in the United States between 1998 and 2008. The average mortality rate for TKA was 0.13% and 0.18% for THA, or 0.34 and 0.44 events per 1,000 inpatient days, respectively. Independent risk factors for in-hospital mortality were advanced age, male gender, ethnic minority background, emergency admission as well as a number of comorbidities and complications. Furthermore, we demonstrated that the timing of death occurred earlier after TKA when compared to THA, with 50% of fatalities occurring by day 4 versus day 6 of the hospitalization, respectively. This study provides nationally representative information on risk factors for and timing of perioperative mortality after TKA and THA. Our data can be used to assess the risk for perioperative mortality and to develop targeted intervention to decrease such risk. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1811-1821, 2012 [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To evaluate the effect of ventilation strategy on markers of inflammation in patients undergoing spine surgery in the prone position. Design: Randomized controlled trial. Setting: University-affiliated teaching hospital. Patients: 26 ASA physical status 1 and 2 patients scheduled for elective primary lumbar decompression and fusion in the prone position. Interventions: Patients were randomized to receive mechanical ventilation with either a tidal volume (VT) of 12 mL/kg ideal body weight with zero positive end-expiratory pressure (PEEP) or VT of 6 mL/kg ideal body weight with PEEP of 8 cm H2O. Measurements: Plasma levels of interleukin (IL)-6 and IL-8 were determined at the beginning of ventilation and at 6 and 12 hours later. Urinary levels of desmosine were determined at the beginning of ventilation and on postoperative days 1 and 3. Main Results: A significant increase in IL-6, IL-8, and urine desmosine levels was noted over time compared with baseline (P < 0.01). However, no significant difference in the levels of markers was seen between the groups at any time point when controlling for demographics, ASA physical status, body mass index, duration of ventilation, or estimated blood loss. Conclusions: Although markers of inflammation are increased after posterior spine fusion surgery, ventilation strategy has minimal impact on markers of systemic inflammation. [Copyright &y& Elsevier]

The article explores whether metabolic syndrome is an independent risk factor for increased major perioperative complications, cost, length of stay, and nonroutine discharge. Results suggest that the prevalence of metabolic syndrome and the comorbidities of the patients increased. Patients with metabolic syndrome had longer length of stay, high hospital costs, higher rates of nonroutine discharges, and increased rates of major life-threatening complications.

Abstract: Study Objective: To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery. Design: Retrospective analysis of a national database. Setting: Freestanding and hospital-based ambulatory surgery facilities. Measurements: Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed. Main Results: Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition was for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional or general [OR 0.34 (CI 0.18; 0.68)]. Conclusions: The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general or regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care. [Copyright &y& Elsevier]

Background: Although anterior (ACDF) and posterior cervical fusion (PCDF) are relatively common procedures and both are associated with certain complications, the relative frequency and severity of these complications is unclear. Since for some patients either approach might be reasonable it is important to know the relative perioperative risks for decision-making. Questions/purposes: The purposes of this study were to: (1) characterize the patient population undergoing ACDF and PCDF; (2) compare perioperative complication rates; (3) determine independent risk factors for adverse perioperative events; and (4) aid in surgical decision-making in cases in which clinical equipoise exists between anterior and posterior cervical fusion procedures. Methods: The National Inpatient Sample was used and entries for ACDF and PCDF between 1998 and 2006 were analyzed. Demographics and complication rates were determined and regression analysis was performed to identify independent risk factors for mortality after ACDF and PCDF. Results: ACDF had a shorter length of stay and their procedures were more frequently performed at nonteaching institutions. The incidence of complications and mortality was 4.14% and 0.26% among patients undergoing ACDF and 15.35% and 1.44% for patients undergoing PCDF, respectively. When controlling for overall comorbidity burden and other demographic variables, PCDF was associated with a twofold increased risk of a fatal outcome compared with ACDF. Pulmonary, circulatory, and renal disease were associated with the highest odds for in-hospital mortality. Conclusions: PCDF procedures were associated with higher perioperative rates of complications and mortality compared with ACDF surgeries. Despite limitations, these data should be considered in cases in which clinical equipoise exists between both approaches. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The majority of nosocomial bloodstream infections in critically ill patients originate from an infected central venous catheter (CVC). Catheter-related bloodstream infections (CRBSIs) cause significant morbidity and mortality and increase the cost of care. The most frequent causative organisms for CRBSI are coagulase-negative staphylococci (CoNSs), Staphylococcus aureus, enterococci, and Candida species. The path to infection frequently includes migration of skin organisms at the insertion site into the cutaneous catheter tract, resulting in microbial colonization of the catheter tip and formation of biofilm. Evidence-based strategies for the prevention of CRBSI include behavioral and educational interventions, effective skin antisepsis coupled with maximum barrier precautions, the use of antiseptic dressings, and the use of antiseptic or antibiotic impregnated catheters. Achieving and maintaining very low rates of CRBSI requires a multidisciplinary approach involving the entire health care team, the use of novel technologies in patients with the highest risk of CRBSI, and frequent reeducation of staff. [ABSTRACT FROM AUTHOR]

The article features the study that aims to determine the difference in perioperative outcomes between unilateral total knee arthroplasties (UTKAs) and bilateral total knee arthroplasties (BTKAs) in the U.S. The study analyzes the data from Nationwide Inpatient Sample from 1998 to 2006. Researchers separated data on BTKAs, healthcare-system related and patient demographics, and the incidence of procedure-related complication and in-hospital mortality. The study concludes that BTKAs are more risky compared to UTKAs while BTKAs caused patients to increase their morbidity.

Admission rates of orthopedic patients to intensive care units are increasing. Thus, an intensivist's familiarity with specific problems associated with major joint replacement surgery is of utmost importance in order to meet the needs of this particular patient population. In this article, the authors review the most commonly encountered complications after major hip and knee arthroplasty. Perioperative risk factors for morbidity and mortality and the epidemiology, diagnosis, and treatment of cardiopulmonary complications in this patient population are discussed. Procedure-specific complications such as fat embolism and acrylic bone cement-related issues are reviewed. [ABSTRACT FROM AUTHOR]

The article analyzes data that was collected from 1988 to 2002 for the National Hospital Discharge Survey to elucidate changes in the demographics of lung resections in the U.S. Temporal changes in lung surgery that may help in the construction of health care policies to address the changing needs of and financial burdens on the health care system are identified.

Abstract: Study Objective: To evaluate the potential differences in the type of anesthesia provided to patients of different race, gender, and source of payment undergoing inguinal hernia repair (IHR). Design: Retrospective cohort study. Setting: Ambulatory surgical centers/National Survey of Ambulatory Surgery. Patients: 5810 patients older than 14 years who underwent IHR in an ambulatory surgical center. Interventions: Inguinal hernia repair under different types of anesthesia. Measurements: The association of race, gender, and source of payment with different types of anesthesia for IHR as determined by multivariate regression analysis. Results: Significant discrepancies in the use of various anesthetics between patients of different race, gender, and source of payment were found. Patients identified as black and those of other minority groups were significantly more likely to receive general anesthesia compared with those identified as white (odds ratio [OR] 2.76, confidence interval [CI] 1.96-3.88 and OR 1.66, CI 1.14-2.42, respectively). Those identified as black were less likely to receive epidural anesthesia compared with their white counterparts (OR 0.36, CI 0.14-0.95). Women were less likely than men to undergo IHR with epidural anesthesia (OR 0.5, 95% CI 0.3-0.85). Conclusion: Significant discrepancies in the use of various anesthetics for IHR between patients of different race, gender, and insurance status were found. Despite limitations inherent to secondary data analysis, the findings raise the possibility that nonmedical factors may influence anesthetic management. [Copyright &y& Elsevier]

Abstract: Purpose:: To determine factors associated with patient disposition status other than discharge to their customary residence (DCR) after elective, ambulatory inguinal hernia repair (IHR). Materials and methods:: N =7953 patients who underwent IHR were identified in the National Survey of Ambulatory Surgery (NSAS). Disposition status was examined by age, sex, race, type of anesthetic, anesthesia provider, expected source of payment, laterality of the procedure, facility type and US region. Logistic regression was used to examine independent risk factors for such disposition status. Results:: Independent risk factors for disposition status other than DCR included anesthesia type, anesthesia provider, increasing age of the patient, and bi- versus unilaterality of the procedure. Differences in disposition status were also found by facility type and US region in which the procedure was performed. Discussion:: The increased cost associated with a disposition status other than DCR requires identification of factors that independently contribute to such an outcome. In this study a number of anesthesia related and unrelated factors were identified that may impact on the disposition of patients undergoing ambulatory inguinal hernia repair. In light of limitations inherent to analysis of large databases our results should be interpreted with caution and prospective trials are needed for validation of our findings. The value of our results may lie particularly in the hypothesis generation for such trials. [Copyright &y& Elsevier]

Background Methods Results Conclusion Studies have demonstrated beneficial outcomes associated with timely surgical treatment of hip fracture. Subsequently, practice recommendations changed with 24–48 h as the recommended time for surgery from admission; however, recent data on timing of hip fracture surgery and how this impacts outcomes are lacking.This retrospective cohort study included patients who had a primary diagnosis of hip fracture and underwent a subsequent surgical repair within 3 days of admission (Premier Healthcare claims 2006–2021 data). The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0–1 day, 2 days, and 3 days). Outcomes included any major complication, mortality, and intensive care unit (ICU) admission. Mixed‐effects models measured the association between timing of surgery and outcomes. We report odds ratios (OR) and 95% confidence intervals.Among 501,267 surgical hip fracture patients, 26.0%, 56.0%, and 18.1% of patients received surgery on days 0–1, 2, and 3, respectively. The median ages were 83, 84, and 84 years old, and there were 73.3%, 72.2%, and 68.8% female in each group respectively. Compared with repair on day 0–1, hip fracture surgical treatment on day 2 or day 3 was associated with increased odds of major complications (OR 1.06, 95% CI 1.03–1.08 and OR 1.17, 95% CI 1.13–1.2), mortality (OR 1.08, 95% CI 1.02–1.14 and OR 1.2, 95% CI 1.12–1.28), and ICU admission (OR 1.06, 95% CI 1.04–1.09 and OR 1.36, 95% CI 1.32–1.4) after adjusting major comorbidities; all p < 0.001.Despite the publication of society guidelines in 2015, most fracture patients still received surgery on day 2 or day 3 of admission and were associated with worse outcomes. Balancing optimization of clinical factors with timing of surgery can be challenging, and further research is needed. Nonetheless, our findings reiterate the importance of timely surgical intervention. [ABSTRACT FROM AUTHOR]

This Viewpoint characterizes the evidence base underlying existing interventions to reduce complications and improve patient outcomes after surgery, and emphasizes the need for science to guide extension and development of new interventions in the face of pressures to use length-of-stay (LOS) as the primary measure of enhanced recovery and to use interventions shown effective for one population and setting to others. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Duration of Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents," by S. J. Park and colleagues in the April 15, 2010 issue.

A 36-year-old female with hemoglobin Nottingham (betaFG 5(98) Val → Gly) causing severe hemolytic anemia and chronic thromboembolic pulmonary hypertension presented with symptomatic subacute right lower lobar pulmonary arterial thrombosis requiring surgical pulmonary thrombectomy. We describe a successful, multidisciplinary approach to the problems associated with this disease, particularly with the use of cardiopulmonary bypass and deep hypothermic circulatory arrest. [ABSTRACT FROM AUTHOR]

The authors discuss the prevalence of obstructive sleep apnea (OSA) in the U.S. and its impact on perioperative medicine. They reference a report from the U.S. Centers for Disease Control and Prevention (CDC) which revealed that 1 in 4 men and 1 in 10 women in the U.S. have OSA. They cite a number of factors that limited studies on the effects of OSA on perioperative risks. They also explore the health and economic effects of performing surgery in OSA patients.

The authors reflect on the debate over the risks and benefits of same-day bilateral total knee arthroplasty (BTKA). They argue that the subject is of greater interest by physicians because the number of total joint arthroplasties in general has been rising dramatically. They suggest the need for hospitals and physicians to consider using conservative patient selection criteria to mitigate the increased risk for complication associated with same-day BTKA.

The author discusses studies focusing on the use of perioperative blood transfusions. Topics explored include the morbidity and mortality rates associated with liberal and restrictive blood transfusion strategies, the adverse outcomes linked to blood transfusions such as myocardial infarction, and the medical complications of blood transfusions according to National Surgical Quality Improvement Program data.

Introduction. Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic. Methods. This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization. Results. There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization. Conclusions. From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today. [ABSTRACT FROM AUTHOR]