Total Hip Arthroplasty: COPD and its Effect on Postoperative Complications

Introduction The demand for Total Hip Arthroplasty (THA) has rapidly risen and continues to due to high success rates of this procedure and the growing aging population. Particularly in Chronic Obstructive Pulmonary Disease (COPD), studies have indicated an increased risk of various postoperative complications across several surgery types. Despite the prevalence of COPD, very little has been investigated regarding postsurgical complications in patients with COPD following a THA. The aim of the current study is to utilize the NSQIP database and determine differences in short-term postoperative complications after undergoing THA, comparing patients with and without COPD. Methods In total, 74,814 patients were included in the analysis looking at how COPD contributes to the rates of postoperative complications in primary THA. Data was obtained from the National Surgical Quality Improvement Project Database years 2005-2014, with readmission/reoperation data beginning in 2011. THA cases were selected out of the database using current procedural terminology (CPT) code 27130. On univariate analysis, p-values were calculated using chi-square for categorical variables and one-way ANOVA for continuous variables. On multivariate analysis, logistic regression was used to control for preoperative comorbidities and calculate p-values. Results On multivariate analysis and after controlling for contributing comorbidities, having COPD was found to be an independent predictor of superficial surgical site infection (OR: 1.74), pneumonia (OR: 3.69), reintubation (OR: 2.65) failure to wean (OR: 3.45), urinary tract infection (OR: 1.46), needing a postoperative transfusion (OR: 1.19), and sepsis (OR: 1.97). COPD also independently predicted whether a patient would be discharged home or not (OR: 1.50). Discussion Although COPD has been linked to negative postoperative outcomes across several surgeries, few studies have examined postsurgical complications in patients with COPD following a THA. Our study found patients with COPD to have higher rates of superficial surgical site infection, pneumonia, reintubation, failure to wean, urinary tract infection, needing a postoperative transfusion, and sepsis. COPD also independently predicted whether a patient would be discharged home or not. Managing high-risk surgical patients requires a better understanding of possible complications a patient faces and enhancing perioperative conditions to improve outcomes. Given our study identified certain complications as independent risk factors for patients with COPD, surgeons and other healthcare providers can use this information to more accurately counsel patients and make perioperative adjustments accordingly

The Impact of Anesthesia Type on Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty

Background: Revision total knee arthroplasty is an increasingly common procedure and is effective in treating knee osteoarthritis, but has higher complication rates than primary total knee arthroplasty. Anesthetic choice offers a perioperative risk factor that has been extensively studied in primary total knee arthroplasty, showing favorable results for regional anesthesia compared to general anesthesia. Anesthetic choice in revision total knee arthroplasties can be optimized to reduce complications and improve health outcomes. Methods: A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision total knee arthroplasties between 2007 and 2014 were divided into three anesthesia cohorts. Univariate and multivariate analyses were used to analyze perioperative factors. Results: From 9899 patients, 6435 received general anesthesia, 3098 received regional anesthesia, and 366 received Monitored Anesthesia Care/IV Sedation. Patients receiving general anesthesia had increased risk for six adverse outcomes compared to patients receiving regional anesthesia, and one adverse outcome compared to patients receiving Monitored Anesthesia Care/IV sedation. General anesthesia independently increased risk for deep surgical site infection, urinary tract infection, and sepsis compared with regional anesthesia. General anesthesia was shown to be an independent risk factor for having an extended length of hospital stay compared with regional anesthesia or Monitored Anesthesia Care/IV sedation. Conclusion: Patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia and Monitored Anesthesia Care/IV sedation. Though complication rates remained low, anesthesiologists must consider the implications of anesthetic choice on postoperative outcomes

The Effect of BMI on Rates of Postoperative Complications after Open Reduction and Internal Fixation of Distal Radius Fractures – A Study on the National Surgical Quality Improvement Project Database

Background: A patient’s Body Mass Index (BMI) has a wide variety of correlations in the orthopedic perioperative setting including post-operative complications. With the current increasing obesity epidemic in the population, understanding the effects of BMI across surgical outcomes can help highlight specific populations that may warrant further management. This study examines the outcomes of patients categorized by BMI receiving operative treatment for distal radius fractures. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent operative management for distal radius fractures between 2007 and 2014 were identified and stratified into groups based on World Health Organization BMI guidelines: (1) \u3c18.5, (2) 18.5-24.9, (3) 25-29.9, (4) \u3e30. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after operation. Results: A total of 6,078 subjects were included in this study, with patients who were underweight having the highest percentage of complications at 4.5%. Underweight patients were seen to have an increased likelihood of developing sepsis (p=0.003), myocardial infarction (p\u3c0.001) and progressive renal insufficiency (p\u3c0.001). There were no observed differences seen between BMI groups amongst other comorbidities. Multivariate analysis did not identify BMI as an independent risk factor for any post-operative complications. Conclusion: Relative to non-obese patients (BMI\u3c30), patients with BMI\u3e30 were not observed to be at an increased risk for any post-operative complications. On the contrary patients underweight (BMI\u3c18.5) were found to be at increased risk for developing sepsis, progressive renal insufficiency, and myocardial infarction. Overall complications for operative treatment of distal radius fracture were low for all groups, and patients who stand to benefit from operative treatment should still receive treatment

Impact of Chronic Kidney Disease on Postoperative Complications following Revision Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is a common orthopedic procedure that is becoming increasingly common in the United States. With an aging population the per capita number of TKAs have doubled from 1991 to 2010 and this rate is projected to grow exponentially over the next decade. Chronic kidney disease (CKD), characterized by a gradual loss of kidney function, is a growing national trend in the United States and is associated with medical comorbidities and increased incidence of postoperative morbidity and mortality. CKD is particularly common amongst an aging population, many of whom are likely to receive a TKA at some point in their lifetime. This study examines the impact of pre-operative kidney function on the risk of post-operative complications for revision total knee arthroplasty. Methods: A retrospective cohort study was performed from data collected via the American College of Surgeons National Quality Improvement Program Database from 2005 to 2014. Patients who had underwent revision TKA were identified by CPT code and further stratified based on pre-operative GFR. Univariate and multivariate analyses were conducted appropriately. Results: In total, 8,454 patients were identified for this study. Decreased GFR was shown to have a significant increase in overall complications, pneumonia, renal insufficiency, renal failure, urinary tract infection, sepsis, septic shock, death, extended hospital length of stay and unplanned return to OR. Multivariate analysis revealed GFR to be an independent risk factor for extended length of stay, renal insufficiency and renal failure. Conclusion: This evidence suggests a trend of higher post-operative complication rates among patients with CKD receiving revision TKA, with particular risk stratified based on worsening CKD stage. In particular, patients with less than 30 GFR had an almost 30% chance of incidence for development of a postoperative complication. Surgeons should carefully consider CKD stage and GFR status when determining patients who would appropriately benefit from revision TKA

The Impact of COPD on Peri- and Post-Operative Comorbidity and Complications in Patients Undergoing Revision Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is currently one of the most prevalent orthopedic procedures in the United States used to treat a wide variety of orthopedic conditions and is increasingly more popular among aging Americans. Chronic obstructive pulmonary disease incidence has been steadily rising over the past few decades and it is currently one of the leading causes of death worldwide. Given the increased prevalence of COPD among the aging and elderly, the disease is becoming more common in TKA surgical candidates. Because of this, it is important to understand the impact and relationship of the disease on a broad array of peri- and post-operative comorbidities and complications so that surgeons may more appropriately assess pre-operative risk. Methods: A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision TKA between 2007 and 2014 were identified. These patients were stratified into groups based on the presence or absence of COPD (without COPD = 9370 [94.4%]; with COPD = 551 [5.6%]). The incidence of adverse events following surgery was evaluated with univariate and multivariate analyses where appropriate. Results: This study used 9,921 subjects who underwent revision TKA. A total of 551 patients had COPD [5.6%] and 9,370 did not [94.4%]. Patients with COPD were found to have increased risk of 8 of 9 peri-operative comorbidities and increased risk of 14 of 18 independent post-operative complications as well as increased risk of all-cause post-operative complications. COPD was also found to be an independent risk factor for unplanned return to the OR. Conclusion: Patients with COPD undergoing revision TKA have greater risk for peri- and post-operative comorbidity and complications than those without COPD, with a 28% overall risk for all-cause complications. While risks for independent complications remain relatively low, consideration of COPD status is an important factor to consider when selecting surgical candidates

Effect of Early Discharge on Postoperative Comorbidity and Complications for Patients Undergoing Revision Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is becoming an increasingly common procedure to alleviate knee pain often associated with osteoarthritis (OA) of the knee. As the number of TKAs performed continue to increase, there remains a debate regarding efficacy of discharging patients earlier than the conventional 3-4 days in the postoperative period. A variety of studies have begun to shown that early discharge has an economical benefit, while causing either a reduction or no difference in patient outcomes. This study aims to determine effect of early discharge on postoperative complications in those that undergo revision TKA. Methods: A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision TKA between 2007 and 2014 were identified and stratified into groups based on discharge date. The incidence of adverse events following surgery was evaluated with univariate and multivariate analyses where appropriate. Results: Patients that were discharged earlier were found to be less likely to develop a deep wound infection, urinary tract infection, sepsis or require a reoperation in the OR within 30 days. Furthermore, earlier discharge was found to be an independent risk factor for these complications. Conclusions: Patients that are discharged earlier have a decreased risk for a variety of complications in the postoperative period, while reducing economic burden. If patients are appropriate candidates, surgeons should consider early discharge as a viable option even in the revision TKA population

Perioperative Complications and Impact of Diabetes Mellitus Severity on Revision Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is a common and effective treatment of knee osteoarthritis. As the amount of TKAs performed increases, so does the number of TKA failures and subsequent revisions. Diabetes mellitus (DM) has been shown to increase complications following orthopedic procedures. For these reasons, it is important to understand the association between severity of DM and the risk of perioperative adverse events following revision TKA. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2007 and 2014 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM), or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after revision TKA. Results: A total of 9,921 patients who underwent revision TKA were selected (without DM = 7845 [79.1%]; NIDDM = 1349 [13.6%]; IDDM = 727 [7.3%]). Patients with NIDDM were found to have an increased risk of developing 1 of 20 adverse events studied compared to patients without DM, while patients with IDDM were found to have an increased risk of developing 6 of 20 adverse events compared to patients without DM. Conclusion: Relative to patients with NIDDM, those with IDDM have a greater likelihood of developing more adverse perioperative outcomes than patients without DM. Although complication rates remain relatively low, orthopedic surgeons must consider the implications of diabetes and insulin dependence on patient selection, preoperative risk stratification, and postoperative outcomes