Total knee arthroplasty in a fast-track setting: reasons and risk factors for 90-day readmission

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Reply to Comment on Saku et al. : Reasons and risk factors for ninety day re-admission following primary total knee arthroplasty in a high-volume centre

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Reasons and Risk Factors for Delayed Discharge After Total Knee Arthroplasty Using an Opioid-Sparing Discharge Protocol

Background: In this study, we aimed to assess the length of hospital stay after total knee arthroplasty in a European healthcare setting. We also aimed to investigate risk factors and reasons for delayed discharge when using an opioid-sparing fast-track protocol. Methods: From our institutional database, we retrospectively identified all primary elective unilateral total knee arthroplasties performed during January to December 2015. Both patient-related and surgery-related variables were collected from our databases. Risk factors were analyzed using multivariable logistic regression analysis. Results: The median length of stay (LOS) was 3 days. Independent risk factors for delayed discharge were higher age, higher American Society of Anesthesiologists score, general anesthesia, surgery performed toward the end of the week, longer duration of surgery, longer stay in the post-anesthesia care unit, and shorter preoperative walking distance. The main reasons for delayed discharge were delayed functional recovery and pain. Conclusion: This study identified several independent risk factors for an LOS longer than 3 days. These risk factors add to the current knowledge on which patients have an increased risk of prolonged LOS, and which patients should be targeted when striving to further reduce the LOS. (C) 2019 Elsevier Inc. All rights reserved.Peer reviewe

Reasons and risk factors for ninety day re-admission following primary total knee arthroplasty in a high-volume centre

Purpose We aimed to assess the rates, reasons, and risk factors for 90-day re-admissions after total knee arthroplasty (TKA) in a European healthcare setting. Methods We identified all primary elective TKA procedures performed in 2015 at a single high-volume centre. Patients with unplanned re-admissions within 90 days of primary discharge were compared to a 1:4 control cohort of patients having no relevant re-admission. We calculated re-admission rates, recorded the reasons for re-admission, and identified independent predictors of re-admission. Results The 30-day and 90-day unplanned re-admission rates were 6.5% and 8.0%, respectively. The most common reason for re-admission within 90 days was infection (29.6%), followed by knee pain (14.1%), gastrointestinal complications (8.5%), and haematoma (8.5%). Multivariable logistic regression analysis revealed that the following factors were significant independent predictors of re-admission: asthma, psychiatric disease, pre-operative tibiofemoral valgus angle, and pre-operative knee flexion deficit. Conclusions The re-admission rates in our health-care setting were slightly higher than those previously reported. Independent risk factors for re-admissions included pre-operative mechanical axis, range of motion, asthma, and psychiatric disease. Our present results will facilitate the targeting of new subgroups of TKA patients when developing new interventions to further reduce the total re-admission risk after TKA.Peer reviewe

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits

Background: Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service. Methods: During a 2-month period, we gathered information on every call received by the consultation phone service from patients with TJAs within 90 days of the index TJA procedure. Patients were followed for 2weeks aftermaking a call to detectmajor complications and self-initiated EDvisits. Datawere collected fromelectronic medical charts regarding age, gender, type of surgery, date of discharge, and length of hospital stay. Results: We analyzed 288 phone calls. Calls were mostly related to medication (41%), wound complications (17%), and mobilization issues (15%). Most calls were resolved in the phone consultation. Few patients (13%) required further evaluation in the ED. The consultation service failed to detect the need for an ED visit in 2 cases (0.7%) that required further care. Conclusion: The consultation phone service clearly benefitted patients with TJAs. The service reduced the number of unnecessary ED visits and functioned well in detecting patients who required further care. Most postoperative concernswere related to prescribed medications, wound complications, and mobilization issues. (c) 2017 Elsevier Inc. All rights reserved.Peer reviewe

Pharmacological therapies for the prevention of fractures in men

Publisher Copyright: Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To determine the benefits and harms of bisphosphonates, parathyroid or parathyroid-related protein analogues, denosumab, and romosozumab therapy for the primary and secondary prevention of fractures in men.Peer reviewe

LEMUR: Large European Module for solar Ultraviolet Research. European contribution to JAXA's Solar-C mission

Understanding the solar outer atmosphere requires concerted, simultaneous solar observations from the visible to the vacuum ultraviolet (VUV) and soft X-rays, at high spatial resolution (between 0.1" and 0.3"), at high temporal resolution (on the order of 10 s, i.e., the time scale of chromospheric dynamics), with a wide temperature coverage (0.01 MK to 20 MK, from the chromosphere to the flaring corona), and the capability of measuring magnetic fields through spectropolarimetry at visible and near-infrared wavelengths. Simultaneous spectroscopic measurements sampling the entire temperature range are particularly important. These requirements are fulfilled by the Japanese Solar-C mission (Plan B), composed of a spacecraft in a geosynchronous orbit with a payload providing a significant improvement of imaging and spectropolarimetric capabilities in the UV, visible, and near-infrared with respect to what is available today and foreseen in the near future. The Large European Module for solar Ultraviolet Research (LEMUR), described in this paper, is a large VUV telescope feeding a scientific payload of high-resolution imaging spectrographs and cameras. LEMUR consists of two major components: a VUV solar telescope with a 30 cm diameter mirror and a focal length of 3.6 m, and a focal-plane package composed of VUV spectrometers covering six carefully chosen wavelength ranges between 17 and 127 nm. The LEMUR slit covers 280" on the Sun with 0.14" per pixel sampling. In addition, LEMUR is capable of measuring mass flows velocities (line shifts) down to 2 km/s or better. LEMUR has been proposed to ESA as the European contribution to the Solar C mission.Comment: 35 pages, 14 figures. To appear on Experimental Astronom

LEMUR: Large European Module for Solar Ultraviolet Research

The solar outer atmosphere is an extremely dynamic environment characterized by the continuous interplay between the plasma and the magnetic field that generates and permeates it. Such interactions play a fundamental role in hugely diverse astrophysical systems, but occur at scales that cannot be studied outside the solar system. Understanding this complex system requires concerted, simultaneous solar observations from the visible to the vacuum ultraviolet (VUV) and soft X-rays, at high spatial resolution (between 0.1 and 0.3), at high temporal resolution (on the order of 10 s, i.e., the time scale of chromospheric dynamics), with a wide temperature coverage (0.01 MK to 20 MK, from the chromosphere to the flaring corona), and the capability of measuring magnetic fields through spectropolarimetry at visible and near-infrared wavelengths. Simultaneous spectroscopic measurements sampling the entire temperature range are particularly important. These requirements are fulfilled by the Japanese Solar-C mission (Plan B), composed of a spacecraft in a geosynchronous orbit with a payload providing a significant improvement of imaging and spectropolarimetric capabilities in the UV, visible, and near-infrared with respect to what is available today and foreseen in the near future. The Large European Module for solar Ultraviolet Research (LEMUR), described in this paper, is a large VUV telescope feeding a scientific payload of high-resolution imaging spectrographs and cameras. LEMUR consists of two major components: a VUV solar telescope with a 30 cm diameter mirror and a focal length of 3.6 m, and a focal-plane package composed of VUV spectrometers covering six carefully chosen wavelength ranges between 170 Angstrom and 1270 Angstrom. The LEMUR slit covers 280 on the Sun with 0.14 per pixel sampling. In addition, LEMUR is capable of measuring mass flows velocities (line shifts) down to 2 km s 1 or better. LEMUR has been proposed to ESA as the European contribution to the Solar C mission

Poikkeamat (polven ja lonkan) tekonivelkirurgian hoitoprosessissa

Total joint arthroplasty (TJA) is the gold-standard treatment for severe hip and knee osteoarthritis. In recent decades, the hospital length of stay (LOS) has reduced substantially largely due to the widespread implementation of fast track protocols. Although the results are now better than ever and most patients have joint replacement without complications, some patients experience one or several deviations from the fast track protocol. In healthcare systems similar to those in Finland, knowledge on these deviations is sparse. This doctoral thesis sought to elucidate some of the deviations in TJA in a Finnish healthcare system. The study population consisted of TJA (i.e. total hip arthroplasty [THA] and total knee arthroplasty [TKA]) patients that underwent surgery at Helsinki University Hospital between 2014 and 2017. The study aimed to identify the reasons and risk factors for delayed discharge and 90-day readmissions after primary TKA. The study also aimed to assess early postoperative emergencies by evaluating the use of an Emergency Response Team (ERT) in the arthroplasty ward. Lastly, the study aimed to evaluate a novel phone consultation service for TJA patients and thereby elucidate common post-discharge concerns. The median LOS after TKA was 3 days. The main reasons for delayed discharge were related to functional recovery and pain. Risk factors for a discharge after the third postoperative day were older age, higher American Society of Anaesthesiologists (ASA) score, shorter preoperative walking distance, general anaesthesia, longer duration of surgery, longer time spent in Post-Anaesthesia Care Unit, and surgery later in the week. The 90-day readmission rate was 8.0% after primary TKA. The most common reasons for readmission were surgical site infection and knee pain. Independent predictors of readmission were psychiatric disease, asthma, a preoperative valgus malalignment, and a preoperative knee flexion deficit. The rate of ERT calls was approximately 7 per 1000 admissions. The most common criteria that triggered the ERT call were decreased level of consciousness, hypotension, and low oxygen saturation. Half of the patients could be treated at the ward after ERT intervention, and the other half was moved to the Intensive Care Unit. Common causes of the emergency included drug-related side effects, pneumonia, and pulmonary embolism. Concerns regarding prescribed medication, wound problems, and mobilization triggered most of the phone consultation service calls. The answering nurse alone resolved two thirds of all calls. Thirteen percent of the patients received instructions to visit the Emergency Department (ED) and half of them had a condition requiring treatment. Only two patients (0.7%) that should have been directed to the ED did not receive such instructions. This study identified several new risk factors for deviations in TJA. Due to the single-payer healthcare system, the possible confounding effect of insurance status did not confound the results. Despite differences in healthcare systems, both LOS and the readmission rate were similar to those previously reported. Considering the present study, a phone consultation service seems to reduce the amount of unnecessary ED visits. Employing an ERT service likely reduces the amount of ICU admissions after TJA surgery.Tekonivelleikkaus on pitkälle edenneen polven ja lonkan nivelrikon ensisijainen hoitomuoto. Viimeisten vuosikymmenten aikana hoitoajat ovat lyhentyneet huomattavasti ns. fast track -hoitoketjun avulla. Vaikka tulokset ovat laajalti parantuneet, ja suurin osa potilaista kotiutuu viimeistään kolmantena leikkauksen jälkeisenä päivänä, ilmenee osalle potilaista yksi tai useampi poikkeama hoitoketjussa. Näistä poikkeamista tiedetään hyvin vähän Suomen kaltaisessa terveydenhuoltojärjestelmässä. Tämän tutkimuksen tarkoituksena oli selvittää syitä usealle yleiselle poikkeamalle polven ja lonkan tekonivelleikkauksen jälkeen. Tutkimus koostui vuosien 2014 ja 2017 välillä Helsingin yliopistollisessa keskussairaalassa tehdyistä polven ja lonkan tekonivelleikkauksista. Tutkimuksen tavoitteena oli selvittää syyt ja riskitekijät myöhästyneelle kotiutumiselle ja osastolle uudelleen joutumiselle. Toisena tavoitteena oli arvioida hätäryhmän (Emergency Response Team, ERT) toimintaa tekonivelosastolla. Tämän lisäksi tutkimuksessa arvioitiin tekonivelpotilaiden puhelinpalvelun toimivuutta ja selvitettiin yleisimmät huolenaiheet kotiutumisen jälkeen. Hoitojakson mediaanipituus polven ensitekonivelleikkauksen jälkeen oli kolme päivää. Yleisimmät syyt kotiutumisen viivästymiselle olivat hidas mobilisaatio ja kipu. Riskitekijöitä kotiutumisen viivästymiselle olivat korkea ikä, korkea ASA-luokka, lyhentynyt kävelymatka ennen leikkausta, yleisanestesia, pidempi leikkaus, pidempi vietetty aika heräämössä sekä leikkaus viikon loppupuolella. Kahdeksan prosenttia potilaista joutui uudelleen osastolle yhdeksänkymmenen päivän kuluessa polven tekonivelleikkauksesta. Yleisimmät syyt olivat leikkausalueen infektio ja polvikipu. Riskitekijöitä osastolle uudelleen joutumiselle olivat psyykkinen sairaus, astma, valgus-virheasento sekä polven koukistusvajaus. ERT-hälytyksiä oli noin seitsemän tuhatta potilasta kohden. Yleisimmät hälytyksen laukaisevat kriteerit olivat tajunnantason lasku, matala verenpaine ja huono hapettuminen. Puolet potilaista pystyttiin hoitamaan osastolla ERT-ryhmän intervention jälkeen, ja puolet potilaista jouduttiin siirtämään tehovalvontaosastolle. Yleisimmät syyt potilaan tilan äkilliselle romahtamiselle olivat lääkkeen sivuvaikutus, keuhkokuume ja keuhkoveritulppa. Epäselvyydet reseptilääkkeiden käytöstä, haavaongelmat ja mobilisaatioon liittyvät ongelmat olivat yleisimmät syyt, jotka johtivat yhteydenottoon tekonivelpotilaiden puhelinpalveluun. Hieman yli kahdessa kolmasosassa puheluista huolenaihe ratkesi hoitajan antamien ohjeiden avulla. Kolmetoista prosenttia potilaista ohjeistettiin käymään päivystyksessä, ja puolet heistä sai hoitoa vaativan diagnoosin. Ainoastaan kaksi potilasta (0.7%), joiden olisi pitänyt hakeutua päivystykseen, eivät saaneet ohjeita hakeutua sinne. Tässä tutkimuksessa tunnistettiin useita uusia riskitekijöitä, jotka altistavat poikkeamille tekonivelleikkauksen hoitoketjussa. Sekä hoitojakson pituus että osastolle uudelleen joutumisen riski olivat kansainvälisiin tuloksiin verrattuna samankaltaisia, vaikka terveydenhuoltojärjestelmien välillä on suuria eroja. Tämän tutkimuksen valossa tekonivelpotilaille tarkoitettu puhelinpalvelu on hyvä tapa hoitaa leikkauksen jälkeisiä huolia, ja se todennäköisesti estää turhia päivystyskäyntejä. ERT-ryhmä näyttäisi vähentävän tehohoidon tarvetta tekonivelleikkauksen jälkeen