Article

Postoperative Morbidity and Mortality in Type-2 Diabetics After Fast-Track Primary Total Hip and Knee Arthroplasty

January 2015
Anesthesia & Analgesia 120(1):230-8

Source
PubMed

Authors:

Region Hovedstaden

Diabetes is a risk factor for postoperative morbidity, which includes total hip and knee arthroplasty. However, no previous studies have been done in a fast-track setting with optimized perioperative care, including spinal anesthesia, multimodal opioid-sparing analgesia, early mobilization, and discharge to home, which improved postoperative outcome. We performed an observational cohort study using prospective data in primary total hip and total knee arthroplasty with a standardized fast-track approach. Eight hundred ninety type 2 diabetics were successfully propensity matched with 7165 nondiabetics. Subanalyses on antihyperglycemic treatment were done using the Danish National Database of Reimbursed Prescriptions for information on dispensed prescriptions 6 months preoperatively. Length of hospital stay (LOS), 90-day readmissions, and mortality were found through the Danish National Health Registry and medical charts. Multiple logistic regression analyses on LOS > 4 days and readmissions were used to further adjust for demographics, comorbidity, and department of surgery. To further evaluate the clinical relevance of type 2 diabetes, we estimated the number of surgical type 2 diabetics needed for 1 more occurrence of LOS > 4 days or readmissions (adjusted number needed to harm [NNH]). Although more type 2 diabetics (11.3%) than nondiabetics (8.1%) had LOS > 4 days (unadjusted P = 0.001), there was no association between type 2 diabetes and LOS > 4 days when adjusting for covariates (odds ratio: 1.19 [0.93-1.54]; P = 0.172). Correspondingly, the NNH was 78 but ranged between 31 and infinity. Type 2 diabetes was not associated with 30- (1.02 [0.75-1.39]; P = 0.897) or 90-day readmissions (1.22 [0.87-1.71]; P = 0.254), and with an NNH of 957 (59-∞) and 115 (35-∞), respectively. Insulin-treated type 2 diabetes was associated with increased risk of specific "diabetes-related" morbidity (1.95 [1.13-3.35]; P = 0.016). Type 2 diabetes per se has limited influence on postoperative morbidity in fast-track total hip and knee arthroplasty.

Postoperative morbidity and asscociated risk-factors in fast-track total hip and knee arthroplasty

Thesis

Full-text available

Aug 2022

Christoffer C Jørgensen

My doctoral thesis summarising 11 studies on postoperative morbidity and risk-factors in fast-track total hip and knee arthroplasty. Defended at the University of Copenhagen Nordsjællands Hospital Hillerød August 2022

Insulin Dependence Increases the Risk of Complications and Death in Total Joint Arthroplasty: A Systematic Review and Meta‐(Regression) Analysis

Article

Full-text available

Mar 2021

Objectives To investigate the proportion of insulin‐dependent diabetes mellitus (IDDM) patients among diabetic patients undergoing total joint arthroplasty (TJA) and whether insulin dependence is associated with postoperative complications. Methods A systematic literature search was performed in EMBASE, PubMed, Ovid, Medline, the Cochrane Library, Web of Science, the China Science and Technology Journal Database, and China National Knowledge Infrastructure from the inception dates to 10 September 2019. Observational studies reporting adverse events with IDDM following TJA were included. Primary outcomes were cardiovascular complications, pulmonary complications, kidney complications, wound complications, infection, and other complications within 30 days of surgery. Secondary outcomes were the proportion of IDDM patients among diabetic patients undergoing TJA and its time trend. Results A total of 19 studies involving 85,689 participants were included. Among patients undergoing TJA, 26% of diabetic patients had IDDM. Compared with non‐insulin‐dependent diabetes (NIDDM), the incidences of cardiac arrest (risk ratio [RR], 2.346; 95% confidence interval [CI], 1.553 to 3.546), renal failure (relative risk [RR], 2.758; 95% CI, 1.830 to 4.156), deep incisional surgical site infection (RR, 1.968; 95% CI, 1.107 to 3.533), wound dehiscence (RR, 2.209; 95% CI, 1.830 to 4.156), and death (RR, 2.292; 95% CI, 1.568 to 3.349) were all significantly increased in IDDM. A significant time trend was witnessed for the prevalence of IDDM (P = 0.014). There was no statistical significance for organ/space surgical site infection, thrombotic events (deep venous thrombosis/ pulmonary embolism), and revision rates. Conclusion Insulin‐dependent diabetes is an independent high‐risk factor for increased adverse outcomes relative to NIDDM, suggesting that hierarchical and optimal blood glucose management may contribute to reducing the adverse complications after surgery for these patients. In addition, because the risk of sepsis, deep wound infection, organ/space surgical site infection, urinary tract infection, renal insufficiency, and renal failure significantly increase after TJA in IDDM patients, more active postoperative antimicrobial prophylaxis may be needed on the premise of protecting renal function.

Excellent Functional Outcome and Quality of Life after Primary Cementless Total Hip Arthroplasty (THA) Using an Enhanced Recovery Setup

Article

Full-text available

Feb 2021

Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction; results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p < 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p < 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p < 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction.

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Article

Full-text available

Jan 2020

Background There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system. Objectives To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement. Design (1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness. Setting Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England. Participants Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement. Interventions Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation). Main outcome measures Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years. Results Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole. Limitations Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors. Conclusion No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts. Future work There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals. Study registration This study is registered as PROSPERO CRD42017059473. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Enhanced recovery after surgery—ERAS—principles, practice and feasibility in the elderly

Article

Full-text available

Mar 2018
AGING CLIN EXP RES

This is a short overview of the principles of a novel development in surgery called enhanced recovery after surgery (ERAS) programs. This is an evidence-based approach to perioperative care that has shown to reduce complications and recovery time by 30–50%. The main mechanism is reduction of the stress reactions to the operation. These principles have been shown to be particularly well suited for the compromised patient and hence very good for the elderly people who often have co-morbidities and run a higher risk of complications.

Die Flexion zur Entlassung ist kein Prädiktor der Gelenkfunktion ein Jahr nach KnietotalendoprotheseKnee flexion after hospitalisation is no predictor for functional outcome one year after total knee arthroplasty

Article

Full-text available

Nov 2022

Zusammenfassung Thema In der Knieendoprothetik spielt das Bewegungsausmaß des operierten Gelenks eine wichtige Rolle. Als Qualitätskriterium wird eine Flexion von mindestens 90° zum Entlassungszeitpunkt angesetzt und als prädiktiver Wert für das Outcome ein Jahr nach Operation unterstellt. Dieser Zusammenhang ist dabei allerdings noch nicht belegt und soll in der vorliegenden Arbeit thematisiert werden. Methodik Insgesamt wurden die Daten von 182 Patienten bzw. Gelenken retrospektiv ausgewertet. Outcomes wurden präoperativ, zur Entlassung, nach 6 Wochen und nach einem Jahr postoperativ erfasst. Zur Beantwortung der Fragestellung wurde das Bewegungsausmaß (ROM) des Kniegelenks ermittelt sowie KSS, SF-36, WOMAC, EQ-5D und VAS zur Beurteilung von Funktion und Lebensqualität erhoben. Es wurden 2 Gruppen abhängig vom Erreichen des 90°-Ziels zur Entlassung erstellt und nach 6 Wochen sowie ein Jahr nach Operation miteinander verglichen. Ergebnisse Die Flexion des Kniegelenks zwischen den beiden Gruppen war zum Entlassungszeitpunkt (E) mit 91° gegenüber 70° signifikant unterschiedlich ( p < 0,001). Nach 6 Wochen näherten sich die Flexionswerte auf 112° ± 13° (E > 90°) vs. 106° ± 14° (E < 90°) an ( p = 0,001). Ein Jahr postoperativ konnte bei einer Flexion von durchschnittlich 122° ± 10° (E > 90°) vs. 120° ± 10° (E < 90°) weder ein Unterschied bezüglich der ROM ( p = 0,57) noch bezüglich der Funktion oder Lebensqualität in sämtlichen erhobenen Scores zwischen den beiden Gruppen festgestellt werden. Schlussfolgerung Nach den Ergebnissen dieser Studie ist das 90°-Kriterium kein adäquater Indikator für die mittelfristige Ergebnisqualität nach Knietotalendoprothese. Es kann weder ein Vorteil noch ein Nachteil durch das Erreichen einer 90°-Flexion zum Entlassungszeitpunkt festgestellt werden.

Enhanced Recovery after Surgery: Perspective in Elder Women

Article

Full-text available

Apr 2021

Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.

Implementing fast track surgery in hip and knee arthroplasty using the lean Six Sigma methodology

Article

Jun 2021

Purpose One of the biggest challenges in the health sector is that of costs compared to economic resources and the quality of services. Hospitals register a progressive increase in expenditure due to the aging of the population. In fact, hip and knee arthroplasty surgery are mainly due to primary osteoarthritis that affects the elderly population. This study was carried out with the aim of analysing the introduction of the fast track surgery protocol, through the lean Six Sigma, on patients undergoing knee and hip prosthetic replacement surgery. The goal was to improve the arthroplasty surgery process by reducing the average length of stay (LOA) and hospital costs Design/methodology/approach Lean Six Sigma was applied to evaluate the arthroplasty surgery process through the DMAIC cycle (define, measure, analyse, improve and control) and the lean tools (value stream map), adopted to analyse the new protocol and improve process performance. The dataset consisted of two samples of patients: 54 patients before the introduction of the protocol and 111 patients after the improvement. Clinical and demographic variables were collected for each patient (gender, age, allergies, diabetes, cardiovascular diseases and American Society of Anaesthesiologists (ASA) score). Findings The results showed a 12.70% statistically significant decrease in LOS from an overall average of 8.72 to 7.61 days. Women patients without allergies, with a low ASA score not suffering from diabetes and cardiovascular disease showed a significant a reduction in hospital days with the implementation of the FTS protocol. Only the age variable was not statistically significant. Originality/value The introduction of the FTS in the orthopaedic field, analysed through the LSS, demonstrated to reduce LOS and, consequently, costs. For each individual patient, there was an economic saving of € 445.85. Since our study takes into consideration a dataset of 111 patients post-FTS, the overall economic saving brought by this study amounts to €49,489.35.

Impact of preoperative treatment with antidepressants and/or anxiolytics on outcomes after colorectal surgery with an enhanced recovery programme: A monocentric retrospective study

Article

Jun 2021

Background: Preoperative use of antidepressants and anxiolytics was reported to increase length of hospital stay (LOS) and worsen surgical outcomes. However, the surgical procedures studied were seldom performed with an enhanced recovery programme (ERP). This study investigated whether these medications impaired postoperative recovery after colorectal surgery with an ERP. Methods: The data of all patients scheduled for colorectal surgery between November 2015 and December 2019 prospectively included in our database were analysed. All the patients were managed with the same ERP. Demographic data, risk factors, incidence of postoperative complications, LOS, and adherence to the ERP were compared between patients with and without preoperative antidepressant and/or anxiolytic treatment. Results: Of the 502 patients, 157 (31.3%) were treated with antidepressants and/or anxiolytics. They were older (65.7 vs. 59.5 years, p < 0.001), sicker (higher ASA physical status score, p = 0.001), and underwent surgery more frequently for cancer (73.9% vs. 56.8%, p < 0.001). Overall adherence to ERP (p = 0.99) and adherence to the postoperative items of ERP (p = 0.29), incidence of postoperative complications (35.7% vs. 33.2%, p = 0.61), and LOS (4 [2-7] vs. 4 [2-7], p = 0.99) were similar in the two groups. Conclusions: Our findings suggest that preoperative treatment with antidepressants and/or anxiolytics does not worsen outcome after elective colorectal surgery with an ERP, does not impact adherence to ERP, and does not prolong LOS. ERP seems efficacious in patients treated with these medications, who should therefore not be excluded from this programme.

Impact of Preoperative Anemia on Outcomes of Enhanced Recovery Program After Colorectal Surgery: A Monocentric Retrospective Study

Article

May 2021

Background Anemia is common before major abdominal surgery (35%). It is an independent factor for postoperative complications and longer length of stay (LOS). The aim of this study was to evaluate the extent to which preoperative anemia impacts on enhanced recovery programs (ERP) outcomes.Materials and Methods The data for patients scheduled for colorectal surgery between 2015 and 2019, were analyzed (n = 494). All patients were managed with the same ERP. Demographic data, preoperative risk factors, postoperative complications, LOS and adherence to ERP were compared between anemic and non-anemic patients. Anemia was defined by a hemoglobin concentration < 13 g dL−1 in men and < 12 g dL−1 in women.Results and DiscussionIn total, 173 patients had preoperative anemia. They were older (p < 0.001) and more often male (p = 0.02). The following risk factors were significantly more frequent in the anemic group: renal failure (p = 0.04), malnutrition (p < 0.001), cardiac arrhythmia (p < 0.001), coronaropathy (p = 0.02) and anticoagulant treatment (p < 0.001). Despite more risk factors, anemic patients did not experience more postoperative complications (38.2% vs. 31.2%, p = 0.12). Overall adherence to ERP was similar (18 [16–19] vs. 18 [17–19], p = 0.06). LOS was 4 [3–7] and 3 [2–6.25] days in the anemic and the non-anemic groups, respectively (p < 0.002). Multivariate analysis showed that anemia did not affect LOS (p = 0.27).Conclusion Our study suggests that preoperative anemia does not detract from the benefits of ERP after elective colorectal surgery.

Mortalidad perioperatoria Perioperative mortality

Article

Full-text available

Sep 2020

Mortalidad perioperatoria

Article

Full-text available

Dec 2020

Introducción: La tasa de mortalidad perioperatoria representa un indicador global del acceso seguro a la atención quirúrgica y anestesiológica. Objetivo: Caracterizar los pacientes fallecidos durante el perioperatorio en intervenciones quirúrgicas. Métodos: Se realizó un estudio descriptivo transversal en el servicio de Anestesiología del Hospital Clínico Quirúrgico Arnaldo Milián Castro, provincia Villa Clara, en el periodo período de enero de 2015 a diciembre de 2018. La población estuvo constituida por los pacientes intervenidos quirúrgicamente en dicho hospital (N: 133 724). La muestra fueron los pacientes fallecidos durante el período intraoperatorio y primeras 24 h tras la intervención quirúrgica (n: 77). Resultados: La tasa de mortalidad perioperatoria general fue de 5,76/10 000. Incidencia de mortalidad mayor en hombres (59,7 %), ancianos (75,3 %), con varias comorbilidades asociadas (51,9 %), clase 4 de la ASA (41,5 %), riesgo quirúrgico grupo II (62,3 %), cirugía abdominal (63,6 %), intervenciones de urgencia (88,3 %), bajo una técnica anestésica general (84,4 %) y en el período postoperatorio 24 h (68,8 %). El shock séptico constituyó la principal causa de mortalidad (48,1 %). Conclusiones: Predominaron las defunciones en ancianos con comorbilidades asociadas, alto riesgo anestésico y quirúrgico, intervenidos de urgencia bajo anestesia general, con el shock séptico como principal causa de muerte. La tasa de mortalidad perioperatoria fue similar a naciones de desarrollo socioeconómico equivalente.

Multiple asystole events in a patient undergoing total knee arthroplasty - a case report

Preprint

Full-text available

May 2019

Background: Unexpected cardiac arrest in patients during surgery is associated with high mortality. Reasons are often multifactorial and unclear. Case presentation: This case report describes a patient who developed reversible asystole during knee surgery under general anaesthesia. All diagnostic cardiac examinations were unremarkable. After surgery, the patient showed no further symptoms. Conclusion: To prevent cardiac arrest due to non-cardiac reasons, patients with a high risk for asystole caused by vasovagal reflex or by pain need to be identified. Preoperative conditions such as hypovolemia need to be improved prior to surgery, and additional monitoring should be used. Further investigations to determine the influence of non-cardiac disease and long-term medication are necessary.

Multiple asystoles in a patient undergoing total knee arthroplasty - a case report

Preprint

Full-text available

Mar 2019

Background Unexpected cardiac arrest in patients during surgery is associated with high mortality. Reasons are often multifactorial and not exactly clear. Case presentation Therefore, this case report describes a patient, who developed reversible asystoles during knee surgery under general anesthesia. All diagnostic cardiac examinations were unremarkable. After surgery the patient showed no further symptoms. Conclusion To prevent cardiac arrest due to non-cardiac reasons, patients with high risk for asystole caused by vasovagal reflex or pain need to be identified. Preoperative conditions like hypovolemia need to be improved and additional monitoring should be used. Further investigations to find the influence of non-cardiac disease and long-term medication are necessary.

Präoperatives Management und Patientenschulung in der Fast-Track-EndoprothetikPreoperative management and patient education in fast-track arthroplasty

Article

Feb 2020

Background Patient management and education are essential for successful fast-track hip/knee arthroplasty. Individual risk stratification as well as educational seminars play an important role in optimizing preoperative risk factors.Objectives Preoperative risk factors are discussed, and optimization strategies are highlighted in the context of the current literature. Further, our own results of an interdisciplinary patient seminar and a patient information app shall be discussed.Materials and methodsIn addition to the authorsʼ own strategy concerning preoperative patient management and the execution of the patient information seminar and app, the essential papers from the literature will be discussed.ResultsPreoperative risk factors (diabetes, obesity, anaemia, etc.) bear the danger of a prolonged length-of-stay with increased morbidity and mortality. Preoperative optimization can reduce the risk of complications and minimize the failure of the fast-track pathway. Educational seminars and patient information apps may reduce anxiety and postoperative analgesic consumption.ConclusionA good preoperative patient management in fast-track arthroplasty can reduce the risk of complications and a prolonged length-of-stay. A comprehensive patient education with educational seminars and an app contributes to optimally preparing the patient for surgery.

Assessment on patient outcomes of primary hip replacement: an interrupted time series analysis from ‘The National Joint Registry of England and Wales’

Article

Full-text available

Nov 2019

Objectives Effects of the UK Department of Health’s national Enhanced Recovery After Surgery (ERAS) Programme on outcomes after primary hip replacement. Design Natural experimental study using interrupted time series to assess the changes in trends before, during and after ERAS implementation (April 2009 to March 2011). Setting Surgeries in the UK National Joint Registry were linked with Hospital Episode Statistics containing inpatient episodes from National Health Service trusts in England and patient reported outcome measures. Participants Patients aged ≥18 years from 2008 to 2016. Main outcome measures Regression coefficients of monthly means of length of hospital stay, bed day cost, change in Oxford Hip Scores (OHS) 6 months post-surgery, complications 6 months post-surgery and revision rates 5 years post-surgery. Results 438 921 primary hip replacements were identified. Hospital stays shortened from 5.6 days in April 2008 to 3.6 in December 2016. There were also improvements in bed day costs (£7573 in April 2008 to £5239 in December 2016), positive change in self-reported OHS from baseline to 6 months post-surgery (17.7 points in April 2008 to 22.9 points in December 2016), complication rates (4.1% in April 2008 to 1.7% March 2016) and 5 year revision rates (5.9 per 1000 implant-years (95% CI 4.8 to 7.2) in April 2008 to 2.9 (95% CI 2.2 to 3.9) in December 2011). The positive trends in all outcomes started before ERAS was implemented and continued during and after the programme. Conclusions Patient outcomes after hip replacement have improved over the last decade. A national ERAS programme maintained this improvement but did not alter the existing rate of change.

Rehabilitation after fast-track knee arthroplasty: A scoping review on evidence-based challenges

Article

Jan 2019

Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer

Article

Full-text available

Jul 2019

Introduction Enhanced recovery after surgery (ERAS) pathways have been proven to enhance postoperative recovery, reduce morbidity, and reduce length of hospital stay after colorectal cancer surgery. However, despite the benefits of the ERAS program on short-term results, little is known about its impact on long-term results. Objective The aim of the study was to determine the association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Material and Methodology Between 2013 and 2016, 350 patients underwent laparoscopic colorectal cancer resection in the 2nd Department of General Surgery, Jagiellonian University Medical College, and were enrolled for further analysis. The relationship between the rate of compliance with the ERAS protocol and 3-year survival was analyzed according to the Kaplan–Meier method with log-rank tests. Patients were divided into two groups according to their degree of adherence to the ERAS interventions: Group 1 (109 patients), < 80% adherence, and Group 2 (241 patients), ≥ 80% adherence. The primary outcome was overall 3-year survival. The secondary outcomes were postoperative complications, length of hospital stay, and recovery parameters. Results The groups were similar in terms of demographics and surgical parameters. The median compliance to ERAS interventions was 85.2%. The Cox proportional model showed that AJCC III (HR 3.28, 95% CI 1.61–6.59, p = 0.0021), postoperative complications (HR 2.63, 95% CI 1.19–5.52, p = 0.0161), and compliance with ERAS protocol < 80% (HR 3.38, 95% CI 2.23–5.21, p = 0.0102) were independent predictors for poor prognosis. Additionally, analysis revealed that adherence to the ERAS protocol in Group 2 with ≥ 80% adherence was associated with a significantly shorter length of hospital stay (6 vs. 4 days, p < 0.0001), a lower rate of postoperative complications (44.7% vs. 23.3%, p < 0.0001), and improved functional recovery parameters: tolerance of oral diet (53.4% vs. 81.5%, p < 0.0001) and mobilization (77.7% vs. 96.1%, p < 0.0001) on the first postoperative day. Conclusions and Relevance This study reports an association between adherence to the ERAS protocol and long-term survival after laparoscopic colorectal resection for non-metastatic cancer. Lower adherence to the protocol, independent from stage of cancer and postoperative complications, was an independent risk factors for poorer survival rates.

Multiple asystole events in a patient undergoing total knee arthroplasty - a case report

Article

Full-text available

Jun 2019
BMC Anesthesiol

Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: A systematic review

Article

Full-text available

Jan 2019
J Orthop Surg Res

Background Cardiac complication represents a major cause of morbidity and mortality after total joint arthroplasty, thus necessitating investigation into the associated risks in total hip arthroplasty and total knee arthroplasty. There remains a lack of clarity for many risk factors in the current literature. The aim of this systematic review is to assess the most recent published literature and identify the risk factors associated with cardiac complication in total hip arthroplasty and total knee arthroplasty. Methods Scopus, PubMed, CINHAL, and Cochrane were searched to identify studies published since 2008 reporting on risk factors associated with cardiac complication in elective primary in total hip arthroplasty and total knee arthroplasty in patients ≥18 years old with osteoarthritis. Reported odds ratios, hazard ratios, and relative risk were the principal summary measures collected. The included studies were too heterogeneous to enable meta-analysis. Results Fifteen studies were included in this systematic review. Increasing age and history of cardiac disease were found by most studies to be positively associated with risk of cardiac complication. There was no strong association found between obesity and cardiac complication. The evidence for other risk factors was less clear in the examined literature, although there is suggestive evidence for male gender and cerebrovascular disease increasing risk. Conclusions Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty. Other risk factors commonly attributed to increased risk in non-cardiac surgery including hypertension and obesity require further evaluation in arthroplasty. Systematic review registration A detailed protocol was published in the PROSPERO database (registration number CRD42018095887) for this systematic review.

Evolution of enhanced recovery after surgery: from the beginning of the study of stress to the introduction in emergency surgery

Article

Jan 2018
Khirurgiia

Effectiveness of enhanced recovery program is being earnestly confirmed in various surgical areas. Certain aspects of fast track rehabilitation are analyzed in the article.

Fast-track hip arthroplasty

Article

Dec 2017

Fast-track surgery implies a coordinated perioperative approach aimed at reducing surgical stress and facilitating post-operative recovery. The fast-track programme has reduced post-operative length of stay and has led to shorter convalescence with more rapid functional recovery and decreased morbidity and mortality in total hip arthroplasty. It should now be a standard total hip arthroplasty patient pathway, but fine tuning of the multiple factors in the fast-track pathway is still needed in patients with special needs or high comorbidity burden.

Clinical Outcome Evaluation of Primary Total Knee Arthroplasty in Patients with Diabetes Mellitus

Article

Full-text available

May 2017

Background The aim of this study was to evaluate the safety and clinical outcome of primary total knee arthroplasty in patients with diabetes mellitus. Material/Methods Among the patients who were treated with total knee arthroplasty, there were 98 patients (116 knees) associated with diabetes. Osteoarthritis was diagnosed in 90 patients and rheumatoid arthritis was diagnosed in 8 patients. Various degrees of preoperative knee deformities were found in 82 knees. The average fasting blood glucose was 9.8±3.6 mmol/L at admission. Results The clinical efficacy of TKA was satisfactory in patients with diabetes mellitus. Diabetic patients do not seem to have a significantly higher risk for infection and DVT after TKA. At the final follow-up time point, no prosthesis loosening was found and no revision was needed in any patients. The mean HSS scores increased and the excellent rate was 100%. Conclusions Using perioperative comprehensive assessment of heart and lung function, and by preventing infection and the formation of DVT, we achieved satisfactory early clinical efficacy of TKA in patients with diabetes mellitus.

Fast track in hip arthroplasty

Article

Full-text available

May 2017

Torben Bæk Hansen

‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery. The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures. Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important. In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Article

Full-text available

Sep 2023

Objectives Review of the current and relevant literature to develop a list of evidence‐based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.

Postoperative morbidity and mortality in patients with diabetes after colorectal surgery with an enhanced recovery program: A monocentric retrospective study

Article

Nov 2022

Background Diabetes mellitus may increase the risk of adverse perioperative outcomes and prolong hospital stay. An enhanced recovery program (ERP) reduces surgical stress and its metabolic consequences, so attenuating the impact of preoperative risk factors. We tested the hypothesis that diabetes would have only a minor impact on outcome after colorectal surgery with an ERP. Methods The data for patients scheduled for colorectal surgery between 2015 and 2021, were analyzed (n = 769). All the patients were managed with the same protocol. Demographic data, preoperative risk factors, postoperative complications, and length of stay were compared between patients with and without diabetes. Results In all, 124 patients (16.1%) had diabetes, of whom 30 (24.1%) required insulin. The following preoperative risk factors for postoperative complications were significantly more frequent in the patients with diabetes: age > 70 years, ASA score ≥ III, renal failure, cardiac disease, BMI > 30 kg/m², anemia, and cancer as indication for surgery. Despite more risk factors, patients with diabetes did not experience more overall postoperative complications than controls (OR (95%IC): 0.9 [0.6–1.5], p = 0.85). Length of hospital stay was not significantly longer in patients with diabetes than in those without (4 [2–7] vs. 3 [2–7] days; p = 0.45). Conclusions Despite more risk factors, patients with diabetes did not experience more complications or longer length of stay after colorectal surgery with an ERP. The multimodal, multidisciplinary approach of ERP to reducing surgical stress may thus help mitigate the reported deleterious effects of diabetes.

Morbidité et mortalité postopératoire chez les patients souffrant de diabète après une chirurgie colorectale lors d’un programme de réhabilitation amélioré : étude rétrospective monocentrique

Article

Nov 2022

Résumé Contexte Le diabète sucré peut augmenter le risque de complications périopératoires et prolonger le séjour à l’hôpital. Un programme de réhabilitation améliorée après chirurgie (RAC) réduit le stress chirurgical et ses conséquences métaboliques, atténuant ainsi l’impact des facteurs de risque préopératoires. Nous avons testé l’hypothèse selon laquelle le diabète n’aurait qu’un impact mineur sur les suites opératoires après une chirurgie colorectale lors d’un programme de RAC. Méthodes Les données des patients programmés pour une chirurgie colorectale entre 2015 et 2021 ont été analysées (n = 769). Tous les patients ont été pris en charge avec le même protocole de RAC. Les données démographiques, les facteurs de risque préopératoires, les complications postopératoires et la durée du séjour ont été comparés entre les patients avec et sans diabète. Résultats Au total, 124 patients (16,1 %) étaient diabétiques, dont 30 (24,1 %) étaient traités par insuline. Les facteurs de risque préopératoires suivants pour les complications postopératoires étaient significativement plus fréquents chez les patients diabétiques : âge > 70 ans, score ASA ≥ III, insuffisance rénale, cardiopathie, IMC > 30 kg/m², anémie et cancer comme indication de la chirurgie. Malgré un plus grand nombre de facteurs de risque, les patients diabétiques n’ont pas souffert de plus de complications postopératoires globales que les patients non diabétiques (OR [IC95 %] : 0,9 [0,6–1,5], p = 0,85). La durée de l’hospitalisation n’était pas significativement plus longue chez les patients diabétiques que chez les autres (4 [2–7] jours contre 3 [2–7] ; p = 0,45). Conclusions Malgré un plus grand nombre de facteurs de risque, les patients diabétiques ne présentaient pas plus de complications ni une durée de séjour plus longue après une chirurgie colorectale lors d’un programme de RAC. L’approche multimodale et multidisciplinaire de la RAC pour réduire le stress chirurgical pourrait donc contribuer à atténuer les effets délétères du diabète.

AM-PAC Mobility Scores Predict Non-Home Discharge Following Adult Spinal Deformity Surgery

Article

Jul 2022
SPINE J

Background Context Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC®) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery. Purpose To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery. Study Design/Setting Retrospective review Patient Sample Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included. Outcome Measures Non-home discharge disposition Methods Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold. Results Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge. Conclusions First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

A Look Forward and a Look Back: The Growing Role of ERAS Protocols in Orthopedic Surgery

Article

Apr 2022

The success of enhanced recovery after surgery (ERAS) protocols in improving patient outcomes and reducing costs in general surgery are widely recognized. ERAS guidelines have now been developed in orthopedics with the following recommendations. Preoperatively, patients should be medically optimized with a focus on smoking cessation, education, and anxiety reduction. Intraoperatively, using multimodal and regional therapies like neuraxial anesthesia and peripheral nerve blocks facilitates same-day discharge. Postoperatively, early nutrition with appropriate thromboprophylaxis and early mobilization are essential. As the evidence of their improvement in patient outcomes and satisfaction continues, these pathways will prove invaluable in optimizing patient care in orthopedics.

Patients with insulin-dependent diabetes are at greater risk for perioperative adverse outcomes following total hip arthroplasty

Article

Feb 2021
HIP INT

Background: The prevalence of diabetes mellitus (DM) continues to increase among patients undergoing total hip arthroplasty (THA). It is unclear how insulin use is correlated with risk for adverse outcomes. Methods: A cohort of 146,526 patients undergoing primary THA were identified in the 2005-2017 National Surgical Quality Improvement Program database. Patients were classified as insulin-dependent diabetic (IDDM), non-insulin-dependent diabetic (NIDDM), or not diabetic. Multivariate analyses were used. Results: Compared to patients without diabetes, patients with NIDDM were at increased risk for 4 of 17 perioperative adverse outcomes studied. Patients with IDDM were at increased risk for those 4 and 8 additional adverse outcomes (12 of the 17 studied). Conclusion: These findings have important implications for preoperative risk stratification and quality improvement initiatives.

Same-day Discharge Is Safe and Effective After Implant-Based Breast Reconstruction

Article

Jan 2021

Background: Same-day discharge after mastectomy is a recently described treatment approach. Limited data exist investigating whether same-day discharge can be successfully implemented in patients undergoing mastectomy with immediate implant-based breast reconstruction (IBR). Methods: Patients having mastectomy with IBR from 2013 to 2019 were reviewed. Enhanced recovery with same-day discharge was implemented in 2017. Patient characteristics, oncologic treatments, surgical techniques, and 90-day postoperative complications and reoperations were analyzed comparing enhanced recovery patients with historical controls. Results: A total of 363 patients underwent nipple-sparing (214, 59%) or skin-sparing (149, 41%) mastectomy with 1-stage (270, 74%) or tissue expander (93, 26%) IBR. Enhanced recovery was used for 151 patients, with 79 of these patients (52%) discharged same-day. Overall, enhanced recovery patients experienced a significantly lower rate of 90-day complications (21% vs 41%, P < 0.001), including hematoma (3% vs 11%, P = 0.002), mastectomy flap necrosis (7% vs 15%, P = 0.02), seroma (1% vs 9%, P < 0.001), and wound breakdown (3% vs 9%, P = 0.05). Postoperative complication rates did not significantly differ among enhanced recovery patients discharged same day. Postoperative admissions significantly decreased after enhanced recovery implementation (100% to 48%, P < 0.001), and admitted enhanced recovery patients experienced a lower length of stay (1.2 vs 1.8, P < 0.001). Enhanced recovery patients experienced a lower incidence of ≥1 unplanned reoperation (22% vs 33%, P = 0.01); overall average unplanned and total reoperations did not significantly differ between groups. Conclusions: In conjunction with enhanced recovery practices, same-day discharge after mastectomy with IBR is a safe and feasible treatment approach.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures

Article

Nov 2020

Background: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. Methods: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. Results: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1-3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3-3.7], P< .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P= .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. Conclusions: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study

Article

Aug 2020
CLIN NUTR

Rationale Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients. Methods 160 patients (116 women and 44 men; age 80 ±10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups. Results Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glucose control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3 %), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3 %) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4 %) respectively, p=NS. There were no differences in 30-day complications (p=0.55) or 1-year mortality (p=0.35) between the groups. Conclusion Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.

Post-operative Nausea and Analgesia Following Total Mastectomy is Improved After Implementation of an Enhanced Recovery Protocol

Article

Aug 2020

Background Enhanced Recovery Protocols (ERPs) provide a multimodal approach to perioperative care, with the aims of improving patient outcomes while decreasing perioperative antiemetic and narcotic requirements. With high rates of post-operative nausea or vomiting (PONV) following total mastectomy (TM), we hypothesized that our institutional designed ERP would reduce PONV while improving pain control and decrease opioid use.Methods An ERP was implemented at a single institution for patients undergoing TM with or without implant-based reconstruction. Patients from the first two months of implementation (ERP group, N = 72) were compared with a retrospective usual-care cohort from a three-month period before implementation (UC group, N = 83). Outcomes included PONV incidence, measured with antiemetic use; patient-reported pain scores; perioperative opioid consumption, measured by oral morphine equivalents (OME); and length of stay (LOS).ResultsThe characteristics of the two groups were similar. PONV incidence and perioperative opioid consumption were lower in the ERP than the UC group (21% vs. 40%, p 0.011 and mean 44.1 OME vs. 104.3 OME, p < 0.001), respectively. These differences in opioid consumption were observed in the operating room and post-anesthesia care unit (PACU); opioid consumption on the floor was similar between the two groups. Patient-reported pain scores were lower in the ERP than the UC group (mean highest pain score 6.4 vs. 7.4, p 0.003). PACU and hospital LOS were similar between the two groups.ConclusionERP implementation was successful in decreasing PONV following TM with and without reconstruction, while simultaneously decreasing overall opioid consumption without compromising patient comfort.

Perioperative Nutrition: Recommendations from the ESPEN Expert Group

Article

Apr 2020
CLIN NUTR

Background and aims Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Anesthesia Considerations

Chapter

Apr 2020

Over the past decade, there has been a growing interest in performing primary total joint arthroplasty in an outpatient setting. One of the most important factors in making this a reality is the development of rapid recovery anesthesia protocols and utilization of multidisciplinary care teams focused on getting the patient discharged home as quickly and safely as possible. With an increasing number of total hip and knee replacements being performed at freestanding surgery centers, the immediate safety net of a hospital is no longer available. Careful patient selection and appropriate anesthesia administration tailored to the outpatient setting have become paramount. Anesthesiologists now play a greater role in screening patients, minimizing narcotic administration, and facilitating early ambulation. It is critical that both the surgeon and the anesthesiologist understand the shared goals of treatment in order to give them the best chance to provide a positive and safe experience during outpatient surgery for their patients.

Preoperative Medical Optimization

Chapter

Mar 2020

Matthias Stopfkuchen-Evans

Over the last decade, preoperative testing centers have become the cornerstone for preoperative evaluation of patients presenting for elective surgery. This was aimed to provide appropriate information about comorbidities to the surgeon and anesthesiologist in a timely manner and to reduce last-minute cancelations due to missing reports or the need for further testing. These clinics have oftentimes limited their activity to collecting data on patients but have fallen short on analyzing and optimizing patients whenever possible. With the expansion of the enhanced recovery after surgery (ERAS) principle to include preoperative optimization of medical comorbidities and improving the patients’ resilience to surgical and perioperative stress through improving cardiovascular fitness, pulmonary reserve, nutrition, and psychological strength, early experience shows encouraging data on patients becoming surgically fit before undergoing oftentimes invasive and high-risk procedures. This chapter aims at summarizing current evidence for the utility of assessing the perioperative risk and preoperative optimization of modifiable medical comorbidities before elective surgery.

Enhanced Recovery After Surgery (ERAS) Protocols in Orthopedic Patients

Chapter

Mar 2020

Ellen M. Soffin

Enhanced recovery after surgery (ERAS) pathways describe perioperative evidence-based care paradigms designed to improve outcomes and reduce morbidity after major surgery. Although ERAS was initially developed and applied to patients undergoing colorectal procedures, today the concepts, principles, and practice of ERAS care have found success in a range of surgical subspecialties, including orthopedic surgery. This chapter presents the method for developing and implementing ERAS pathways in general and how they can be tailored and applied to specific orthopedic procedures. The evidence underlying ERAS efficacy in elective total joint arthroplasty (including hip, knee, and shoulder) is presented. Further, emerging areas of ERAS research and practice are considered, including how ERAS may benefit care of the patient undergoing hip fracture repair, revision joint arthroplasty, and spine surgery.

Knie- und Hüfttotalendoprothese in 2 TagenTotal knee and hip arthroplasty within 2 days: Das dänische Fast-Track-ModellThe Danish Fast-Track Model

Article

Aug 2019

Background Patients in Denmark undergoing total knee or hip replacement are routinely discharged within 2 days of surgery. A critical examination of traditional treatment methods, combined with focused research, has during the last 20 years increasingly optimized the treatment course in such a way that it has become possible to radically reduce the length of stay (LOS). Basics of the Fast-Track model The most important elements of this Fast-Track model are described. The patient motivation and transfer of partial responsibility to the patient through intensive information, optimized operation techniques, as well as modern multi-modal pain therapy with early mobilization are key issues. The relatively small and homogenous health care system of Denmark offers good research conditions and the possibility of a fast implementation of the latest results, as well as a lump-sum based re-imbursement system without minimum stay—both factors have been favorable for the development of the Fast-Track model.

Impact of a National Enhanced Recovery After Surgery Programme on Patient Outcomes of Primary total Knee Replacement: an Interrupted Time Series Analysis from “The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man”

Article

Full-text available

May 2019

Objective We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes. Design Natural-experiment (April 2008–December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation. Setting Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs). Participants Patients undergoing primary planned TKR aged ≥18 years. Intervention ERAS implementation (April 2009–March 2011). Outcomes Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years). Results 486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased. Conclusions Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Author's manuscript

Data

Full-text available

Jul 2018

Impact of comorbid conditions on outcomes of hip and knee replacement surgery: A systematic review and meta-analysis

Article

Full-text available

Jul 2018

Objective To systematically perform a meta-analysis of the association between different comorbid conditions on safety (short-term outcomes) and effectiveness (long-term outcomes) in patients undergoing hip and knee replacement surgery. Design Systematic review and meta-analysis. Methods Medline, Embase and CINAHL Plus were searched up to May 2017. We included all studies that reported data to allow the calculation of a pooled OR for the impact of 11 comorbid conditions on 10 outcomes (including surgical complications, readmissions, mortality, function, health-related quality of life, pain and revision surgery). The quality of included studies was assessed using a modified Newcastle-Ottawa Scale. Continuous outcomes were converted to ORs using the Hasselblad and Hedges approach. Results were combined using a random-effects meta-analysis. Outcomes The primary outcome was the adjusted OR for the impact of each 11 comorbid condition on each of the 10 outcomes compared with patients without the comorbid condition. Where the adjusted OR was not available the secondary outcome was the crude OR. Results 70 studies were included with 16 (23%) reporting on at least 100 000 patients and 9 (13%) were of high quality. We found that comorbidities increased the short-term risk of hospital readmissions (8 of 11 conditions) and mortality (8 of 11 conditions). The impact on surgical complications was inconsistent across comorbid conditions. In the long term, comorbid conditions increased the risk of revision surgery (6 of 11 conditions) and long-term mortality (7 of 11 conditions). The long-term impact on function, quality of life and pain varied across comorbid conditions. Conclusions This systematic review shows that comorbidities predominantly have an impact on the safety of hip and knee replacement surgery but little impact on its effectiveness. There is a need for high-quality studies also considering the severity of comorbid conditions.

Rapid Recovery Total Joint Arthroplasty is Safe,Efficient, and Cost Effective in the Veteran’s Administration Setting

Article

Jul 2018
J ARTHROPLASTY

Background: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. Methods: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. Results: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). Conclusion: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Preoperative High-Dose Methylprednisolone and Glycemic Control Early After Total Hip and Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

Article

Jun 2018
ANESTH ANALG

Background: To evaluate the effect of a single preoperative dose of 125 mg methylprednisolone (MP) on glycemic homeostasis early after fast-track total hip and knee arthroplasty. Methods: One-hundred thirty-four patients undergoing elective unilateral total hip arthroplasty and total knee arthroplasty were randomized (1:1) to preoperative intravenous MP 125 mg (group MP) or isotonic saline intravenous (group C). All procedures were performed under spinal anesthesia, using a standardized multimodal analgesic regime. The primary outcome was the change in plasma glucose 2 hours postoperatively, and secondary outcomes included plasma C-peptide concentrations, homeostatic model assessment (HOMA), HOMA-IR (insulin resistance), and HOMA-B (β-cell function). Fasting blood samples were collected at baseline and 2, 6 (nonfasting), 24, and 48 hours after surgery with complete samples from 122 patients (group MP = 62, group C = 60) for analyses. Results: MP patients had increased plasma glucose levels at 2 hours (adjusted mean [95% CI], 7.4 mmol·L [7.2-7.5] vs 6.0 mmol·L [5.9-6.2]; P = .023) and 6 hours (13.9 mmol·L [13.3-14.5] vs 8.4 mmol·L [7.8-9.0]; P < .001), and in plasma C-peptide 24 hours postoperatively (1675 pmol·L [1573-1778] vs 1248 pmol·L [1145-1351]; P < .001). An impaired insulin response was also observed in group MP as reflected by HOMA-B (P < .001). Additionally, HOMA-IR increased 24 hours postoperatively in group MP compared to group C (P < .001). Parameters were normalized 48 hours postoperatively. Conclusions: Preoperative administration of MP 125 mg resulted in a transient postoperative increase in plasma glucose and insulin resistance and impaired insulin secretion in response to hyperglycemia.

ERAS-Value based surgery

Article

Sep 2017

This paper reviews implementation of ERAS and its financial implications. Literature on clinical outcomes and financial implications were reviewed. Reports from many different surgery types shows that implementation of ERAS reduces complications and shortens hospital stay. These improvements have major impacts on reducing the cost of care even when costs for implementation, and investment in time for personnel and training is accounted for. The conclusion is that ERAS is an excellent example of value based surgery.

Safety aspects of preoperative high-dose glucocorticoid in primary total knee replacement

Article

Aug 2017

Background: Preoperative single high-dose glucocorticoid may have early outcome benefits in total hip arthroplasty (THA) and knee arthroplasty (TKA), but long-term safety aspects have not been evaluated. Methods: From October 2013, the departments reporting to the prospective Lundbeck Foundation Database for Fast-track Hip and Knee Replacement introduced preoperative methylprednisolone (MP) 125 mg as part of a multimodal analgesic protocol in TKA. We analysed the risk of length of hospital stay (LOS) >4 days, 30 and 90 day readmissions in patients with MP vs patients having TKA before the use of MP and adjusted for comorbidity and place of surgery. An unadjusted comparison was specifically done to evaluate deep prosthetic infections. Results: Of a total of 3927 TKA procedures, 1442 received MP. Median LOS was 2 days in both groups, but the fraction with LOS >4 days was 6.0% vs 11.5% (P<0.001) in patients with MP vs those without, and with a reduced risk of LOS >4 days in adjusted analysis [odds ratio (OR) 0.51; confidence interval (CI) 0.39-0.68; P <0.001]. Readmission rates were 5.6% (CI 4.5-6.9) vs 4.4% ( P =0.095) and 7.8% vs 7.3% ( P =0.53) at 30 and 90 days with and without MP, respectively. Conclusions: In this detailed prospective cohort study, preoperative high-dose glucocorticoid administration was not associated with LOS >4 days, readmissions or infectious complications in TKA patients without contraindications.

Enhanced recovery after surgery for hip and knee arthroplasty: A systematic review and meta-analysis

Article

Full-text available

Jul 2017

Objectives To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis. Results A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p<0.01), and there were fewer incidences of complications in the ERAS group than in the control group (p=0.03). However, no significant difference was found in the 30-day readmission rate (p=0.18). Conclusions ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.

Effect of Type 2 Diabetes on In-Hospital Postoperative Complications and Mortality After Primary Total Hip and Knee Arthroplasty

Article

Jul 2017

Background We aimed to compare in-hospital postoperative complications (IHPC) and in-hospital mortality (IHM) between patients with and without type 2 diabetes mellitus (T2DM) undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods We analyzed data from the Spanish National Hospital Discharge Database, 2010-2014. We selected patients who had undergone THA (ICD-9-CM code 81.51) and TKA (code 81.54). Diabetic patients with THA and TKA were matched by year, age, sex, and the comorbidities included in the modified Elixhauser Comorbidity Index with a non-diabetic patient. Results We identified 115,234 THA patients and 195,355 TKA patients, 12.4% and 15.6% with T2DM, respectively. We matched 10,777 and 26,640 pairs of diabetic and non-diabetic patients. In T2DM patients who had undergone THA, the incidence of urinary tract infection was higher than in non-diabetic patients (1.50% vs 1.09%; p=0.007), as was that of “any IHPC” (9.68% vs 8.98%; p=0.038). In patients who had undergone TKA, the incidence of postoperative anaemia was significantly higher in diabetic patients (4.90% vs. 4.53;p=0.040), as was that of urinary tract infection (0.80% vs. 0.53%;p=0.025) and “any IHPC” (7.30% vs 6.76%;p=0.014). In both procedures, mean length of hospital stay was significantly higher in diabetic patients; for TKA, IHM was higher in diabetic patients (0.09% vs 0.02%;p=0.002). Previous comorbidities, age, and obesity predict a higher incidence of IHPC among diabetic patients. Conclusions This study confirms the higher risk of IHPC among T2DM patients after joint arthroplasty. IHPC may result in a higher risk of mortality in patients undergoing TKA.

Comparison of Perioperative Adverse Event Rates Following Total Knee Arthroplasty in Patients with Diabetes: Insulin Dependence Makes a Difference

Article

May 2017

Background Total knee arthroplasty (TKA) is an effective treatment option for patients with advanced osteoarthritis and has become one of the most frequently performed orthopaedic procedures. With the increasing prevalence of diabetes mellitus (DM), the burden of its sequelae and associated surgical complications has also increased. For these reasons, it is important to understand the association between DM and the rates of perioperative adverse events following TKA. Methods A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients who underwent TKA between 2005 and 2014 were identified and characterized as having insulin dependent diabetes mellitus (IDDM), non-insulin dependent diabetes mellitus (NIDDM), or not having DM. Multivariate Poisson regression was used to control for demographic and comorbid factors and to assess the relative risks of multiple adverse events in the initial 30 postoperative days. Results A total of 114,102 patients who underwent TKA were selected (IDDM = 4,881 [4.3%], NIDDM = 15,367 [13.5%], no DM = 93,854 [82.2%]). Patients with NIDDM were found to be at greater risk for 2 of 17 adverse events studied relative to patients without DM. However, patients with IDDM were found to be at greater risk for 12 of 17 adverse events studied relative to patients without DM. Conclusion In comparison to patients with NIDDM, patients with IDDM are at greater risk for many more perioperative adverse outcomes relative to patients without DM. These findings have important implications for patient selection, preoperative risk stratification, and postoperative expectations.

Enhanced Recovery After Surgery (ERAS®) in Individuals with Diabetes: A Systematic Review

Article

Mar 2017

Background Prevalence of diabetes in surgical patients is 10–40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation. MethodsMEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials. Selection criteriaRandomized controlled trials (RCT) looking at individuals with diabetes undergoing surgery randomized to ERAS® or conventional care. Non-randomized controlled trials, controlled before–after studies, interrupted time series, and cohort studies with concurrent controls were also considered. Two authors independently screened studies. ResultsThe electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS®, did not include patients with diabetes, or used an uncontrolled observational design. Conclusions To date, the effects of ERAS® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.

The Revised Cardiac Risk Index in the new millennium: A single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

Article

Full-text available

Jun 2013
CAN J ANAESTH

Cardiac complications following non-cardiac surgery are major causes of morbidity and mortality. The Revised Cardiac Risk Index (RCRI) has become a standard for predicting post-surgical cardiac complications. This study re-examined the original six risk factors to confirm their validity in a large modern prospective database. Using the definitions in the original risk index, this study included 9,519 patients aged ≥ 50 undergoing elective non-cardiac surgery with an expected length of stay ≥ two days at two major tertiary-care teaching hospitals. The validity of the original predictors was tested in this population using binomial logistic regression modelling, area under the receiver operator curve (ROC) analysis, and the net reclassification index. Rates of major cardiac complications with 0, 1, 2, ≥ 3 of the predictors were 0.5%, 2.6%, 7.2%, and 14.4%, respectively, in our patient cohort compared with 0.4%, 1.1%, 4.6%, and 9.7%, respectively, in the original cohort. Similar to the original report, binary logistic regression analysis showed that both preoperative treatment with insulin (odds ratio [OR] 1.4; 95% confidence interval [CI] 0.7 to 2.6) and preoperative creatinine > 176.8 mmol·L(-1) (OR 1.7; 95% CI 0.8 to 3.6) did not improve the predictive ability of the index. Analysis of the remaining four factors resulted in an area under the curve (AUC) identical to that seen for the reconstructed six-factor RCRI (AUC = 0.79). We found that a glomerular filtration rate (GFR) < 30 mL·min(-1) was a better predictor of major cardiac complications (OR 2.2; 95% CI 1.2 to 4.3) than creatinine > 176.8 mmol·L(-1). The receiver operating characteristic analysis of this resultant 5-Factor model resulted in an AUC of 0.79, with 0, 1, 2, ≥ 3 of the predictors representing 0.5%, 2.9%, 7.4%, and 17.0% risk, respectively, among our patient cohort. Compared with the RCRI, a simplified 5-Factor model using a high-risk type of surgery, a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, and a preoperative GFR < 30 mL·min(-1) results in superior prediction of major cardiac complications following elective non-cardiac surgery.

Role of patient characteristics for fast-track hip and knee arthroplasty

Article

Full-text available

Jan 2013
BRIT J ANAESTH

Background: Patient age and comorbidity have been found to increase the length of hospital stay (LOS), readmissions, and mortality after surgery, including in elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Whether the same applies in fast-track THA and TKA with early mobilization and an LOS aim of 2-4 days remains unanswered. Method: A prospective study on patient characteristics and comorbidity in consecutive unselected patients undergoing fast-track THA and TKA was cross-referenced with the Danish National Health Registry and medical charts allowing complete 90 days follow-up. Results: A total of 3112 THA/TKAs were performed in 3020 patients. The mean age was 67 (range 18-97) years. The median LOS was 3 (inter-quartile range: 1) and the mean 3.0 days (range 1-34), with 91% having LOS ≤4 days. Age 76-80 [odds ratio (OR): 1.57; 95% confidence interval (CI): 0.99-2.47], 81-85 (OR: 2.40; 1.45-4.00), and >85 yr (OR: 4.10; 2.15-7.82), preoperative cardiopulmonary disease (CPD) (OR: 1.40; 1.03-1.91), preoperative use of a mobility aid (OR: 1.95; 1.46-2.54), and living conditions (OR: 1.92; 1.44-2.54) were related to LOS >4 days. However, more than 75% of those aged over 80 yr or with these conditions had an LOS ≤4 days. Mortality and readmission rate were 0.22% and 6.6%, respectively, at 30 days and 0.42% and 9.3% at 90 days. Readmissions were similarly related to older age, CPD, and use of mobility aids. Conclusions: Fast-track THA and TKA with LOS of ≤4 days and discharge to home is feasible and safe, including in elderly patients with comorbidities.

Existing data sources for clinical epidemiology: The Danish National Database of Reimbursed Prescriptions

Article

Full-text available

Nov 2012

The Danish health care system provides partial reimbursement of most prescription medications in Denmark. The dispensation of prescription medications is registered in administrative databases. Each time a prescription is redeemed at a pharmacy, an electronic record is generated with information related to the user, prescriber, the pharmacy, and the dispensed drug. The National Health Service gathers this information for administration of the drug reimbursement plan. Recently, this information became the basis for the establishment of a new research database, the Danish National Database of Reimbursed Prescriptions (DNDRP). In this paper, we review the content, coverage, quality, linkage, access, and research possibilities of this new database. The database encompasses the reimbursement records of all reimbursed drugs sold in community pharmacies and hospital-based outpatient pharmacies in Denmark since 2004. On average, approximately 3.5 million users are recorded in the database each year. During the coverage period, the number of annual prescription redemptions increased by 15%. Most dispensed prescriptions are in the categories "alimentary tract and metabolism", "cardiovascular system", "nervous system", and "respiratory system". Individuals are identified by the unique central personal registration (CPR) number assigned to all persons born in or immigrating to Denmark. The new database fully complies with Denmark's Act on Processing of Personal Data, while avoiding additional restrictions imposed on data use at the Danish National Prescription Registry, administered by Statistics Denmark. Most importantly, CPR numbers are reversibly encrypted, which allows re-identification of drug users; furthermore, the data access is possible outside the servers of Statistics Denmark. These features open additional opportunities for international collaboration, validation studies, studies on adverse drug effects requiring review of medical records, studies involving contact to general practitioners, and linkage of prescription data to other clinical and research databases. The DNDRP thus is a valuable data source for pharmacoepidemiological research.

Fast-track surgery: Procedure-specific aspects and future direction

Article

Full-text available

Sep 2012
LANGENBECK ARCH SURG

Introduction: Fast-track (FT) surgery can be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery. The objective of this review was to examine the literature on the procedure-specific application of FT surgery. Discussion: The concept of FT rehabilitation has been applied mainly in colorectal surgery, but positive data have appeared also in other areas such as orthopedic, hepatopancreaticobiliary, urological, upper gastrointestinal, gynecological, thoracic, vascular, endocrine, breast, and pediatric surgeries. There is very little experience with comprehensive FT programs in cardiac surgery or trauma. Quantitative analysis from randomized trials and cohort studies suggest that FT is effective in reducing hospital stay without increased adverse events. Other benefits of the FT approach include a reduction in complications, ileus, fatigue, pain, and hospital expenses. However, despite clear benefits of FT care, implementation in daily practice has been slow. Further efforts must be undertaken to secure implementation in routine clinical practice. Standardized FT protocols should be provided on a procedure-specific basis.

NHS Diabetes guideline for the perioperative management of the adult patient with diabetes*

Article

Full-text available

Jan 2012
DIABETIC MED

Diabet. Med. 29, 420–433 (2012) These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

Enhanced recovery program for hip and knee replacement reduces death rate: A study of 4,500 consecutive primary hip and knee replacements

Article

Full-text available

Sep 2011
ACTA ORTHOP

Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications. We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications. There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8). This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.

Regional and hospital variance in performance of total hip and knee replacements: A national population-based study

Article

Full-text available

Jun 2011
ANN MED

This article in the supplement on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT)-project describes the PERFECT Hip and Knee Replacement Database and its possibilities by evaluating regional and hospital-level differences in length of stay (LOS), costs and complication rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Finland. All hip and knee arthroplasties are recorded in the Finnish Hospital Discharge Register (FHDR) and Finnish Arthroplasty Register (FAR). LOS, length of uninterrupted institutional care (LUIC), complication rates and other parameters of treatment were determined by region and hospital during 1998-2008 based on these. LOS and LUIC following THA and TKA diminished during the follow-up period. In 1998 average LOS after THA and TKA was 9.9 and 10 days. In 2008, these had shortened to 5.2 and 5.3 days, respectively. There was a 5.0 and 7.5 percentage point difference in revision rate between regions in THAs and TKAs, respectively, performed during 2005-2007 and followed to the end of 2009. The Finnish health care registers provide a monitoring system for evaluating hospital- and regional-level differences in THA and TKA. The differences in LOS, LUIC and revision rates between hospitals and regions are considerable.

Treatment Effects in the Presence of Unmeasured Confounding: Dealing With Observations in the Tails of the Propensity Score Distribution--A Simulation Study

Article

Full-text available

Oct 2010

Frailty, a poorly measured confounder in older patients, can promote treatment in some situations and discourage it in others. This can create unmeasured confounding and lead to nonuniform treatment effects over the propensity score (PS). The authors compared bias and mean squared error for various PS implementations under PS trimming, thereby excluding persons treated contrary to prediction. Cohort studies were simulated with a binary treatment T as a function of 8 covariates X. Two of the covariates were assumed to be unmeasured strong risk factors for the outcome and present in persons treated contrary to prediction. The outcome Y was simulated as a Poisson function of T and all X’s. In analyses based on measured covariates only, the range of PS's was trimmed asymmetrically according to the percentile of PS in treated patients at the lower end and in untreated patients at the upper end. PS trimming reduced bias due to unmeasured confounders and mean squared error in most scenarios assessed. Treatment effect estimates based on PS range restrictions do not correspond to a causal parameter but may be less biased by such unmeasured confounding. Increasing validity based on PS trimming may be a unique advantage of PS's over conventional outcome models.

Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery

Article

Full-text available

Aug 2010

Hospital hyperglycemia, in individuals with and without diabetes, has been identified as a marker of poor clinical outcome in cardiac surgery patients. However, the impact of perioperative hyperglycemia on clinical outcome in general and noncardiac surgery patients is not known. This was an observational study with the aim of determining the relationship between pre- and postsurgery blood glucose levels and hospital length of stay (LOS), complications, and mortality in 3,184 noncardiac surgery patients consecutively admitted to Emory University Hospital (Atlanta, GA) between 1 January 2007 and 30 June 2007. The overall 30-day mortality was 2.3%, with nonsurvivors having significantly higher blood glucose levels before and after surgery (both P < 0.01) than survivors. Perioperative hyperglycemia was associated with increased hospital and intensive care unit LOS (P < 0.001) as well as higher numbers of postoperative cases of pneumonia (P < 0.001), systemic blood infection (P < 0.001), urinary tract infection (P < 0.001), acute renal failure (P = 0.005), and acute myocardial infarction (P = 0.005). In multivariate analysis (adjusted for age, sex, race, and surgery severity), the risk of death increased in proportion to perioperative glucose levels; however, this association was significant only for patients without a history of diabetes (P = 0.008) compared with patients with known diabetes (P = 0.748). Perioperative hyperglycemia is associated with increased LOS, hospital complications, and mortality after noncardiac general surgery. Randomized controlled trials are needed to determine whether perioperative diabetes management improves clinical outcome in noncardiac surgery patients.

Does strict glucose control improve outcome?

Article

Full-text available

Oct 2009
BRIT J ANAESTH

A Review of the Application of Propensity Score Methods Yielded Increasing Use, Advantages in Specific Settings, But Not Substantially Different Estimates Compared with Conventional Multivariable Methods

Article

Full-text available

Jun 2006
J CLIN EPIDEMIOL

Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling. Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003. Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented. Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.

Hypoglycaemia: The limiting factor in the glycaemic management of the critically ill?

Article

Full-text available

Sep 2006

Philip E Cryer

The Science of Improvement

Article

Full-text available

Apr 2008
J Am Med Assoc

Donald M Berwick

In the early 1890s, Dr William Halsted developed radical mastectomy for breast cancer. Surgeons performed the Halsted procedure for more than 80 years even though there was little systematic evidence for its success. Then a new breed of scholars subjected the procedure to formal methods of evaluation unknown to Halsted.1 The methods—randomized controlled trials (RCTs) principal among them—led to a surprise: radical mastectomy had no advantage over simpler forms of treatment.2

Understanding Readmission After Primary Total Hip and Knee Arthroplasty: Who's at Risk?

Article

Aug 2013

Fast-track hip and knee arthroplasty

Article

May 2013
LANCET

Henrik Kehlet

Surgical Outcomes of Total Knee Replacement According to Diabetes Status and Glycemic Control, 2001 to 2009

Article

Feb 2013
J BONE JOINT SURG AM

Background: Poor glycemic control in patients with diabetes may be associated with adverse surgical outcomes. We sought to determine the association of diabetes status and preoperative glycemic control with several surgical outcomes, including revision arthroplasty and deep infection. Methods: We conducted a retrospective cohort study in five regions of a large integrated health-care organization. Eligible subjects, identified from the Kaiser Permanente Total Joint Replacement Registry, underwent an elective first primary total knee arthroplasty during 2001 through 2009. Data on demographics, diabetes status, preoperative hemoglobin A1c (HbA1c) level, and comorbid conditions were obtained from electronic medical records. Subjects were classified as nondiabetic, diabetic with HbA1c < 7% (controlled diabetes), or diabetic with HbA1c ≥ 7% (uncontrolled diabetes). Outcomes were deep venous thrombosis or pulmonary embolism within ninety days after surgery and revision surgery, deep infection, incident myocardial infarction, and all-cause rehospitalization within one year after surgery. Patients without diabetes were the reference group in all analyses. All models were adjusted for age, sex, body mass index, and Charlson Comorbidity Index. Results: Of 40,491 patients who underwent total knee arthroplasty, 7567 (18.7%) had diabetes, 464 (1.1%) underwent revision arthroplasty, and 287 (0.7%) developed a deep infection. Compared with the patients without diabetes, no association between controlled diabetes (HbA1c < 7%) and the risk of revision (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.99 to 1.76), risk of deep infection (OR, 1.31; 95% CI, 0.92 to 1.86), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.84; 95% CI, 0.60 to 1.17) was observed. Similarly, compared with patients without diabetes, no association between uncontrolled diabetes (HbA1c ≥ 7%) and the risk of revision (OR, 1.03; 95% CI, 0.68 to 1.54), risk of deep infection (OR, 0.55; 95% CI 0.29 to 1.06), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.70; 95% CI, 0.43 to 1.13) was observed. Conclusions: No significantly increased risk of revision arthroplasty, deep infection, or deep venous thrombosis was found in patients with diabetes (as defined on the basis of preoperative HbA1c levels and other criteria) compared with patients without diabetes in the study population of patients who underwent elective total knee arthroplasty.

Trends 2001 to 2008 in incidence and immediate postoperative outcomes for major joint replacement among Spanish adults suffering diabetes

Article

Feb 2013

To analyze the trend of incidence rates of primary total knee (TKA) and primary total hip arthroplasty (THA) due to osteoarthritis among Spanish adults suffering diabetes (type-1 and 2) from 2001 to 2008 and analyze in-hospital mortality (IHM), length of stay (LOS) and hospital charges compared with non-diabetic patients. From the Spanish National Hospital Database, we selected 250,205 patients with TKA and 122,926 patients with THA; 12 and 9% of patients undergoing TKA and THA, respectively, were diabetes sufferers, of them, 1.6% was classified as type 1 in each procedure. Incidence of both procedures increased over the period, but diabetic patients had a larger increment compared with non-diabetic patients. The ratio of diabetes versus non-diabetes sufferers undergoing TKA increased from 0.10 in 2001 to 0.16 in 2008 and from 0.08 to 0.11 for THA. Unadjusted IHM was higher among type-2 diabetic adults in both procedures. IHM rate did not show a secular time trend among diabetic patients. LOS was significantly longer among patients with diabetes type-1 and 2 undergoing THP when compared with non-diabetic patients. Hospital charges were higher among diabetic versus non-diabetic patients for both procedures showing a significant increase over the period. Immediate postoperative outcomes for major joint replacement are worse among persons with than without diabetes, and prevalence of diabetes is increasing in patients undergoing these surgeries.

Emerging Trends in Clinical Trial Design

Article

Jan 2013

Therefore, randomized trial methodology was initiated only 6 decades ago. As might be expected from such a young field, the pace of advancement remains high. In this editorial, we discuss 3 emerging trends in clinical trial design. The techniques we discuss may be helpful to investigators who are designing randomized trials. They may also be helpful to department leaders who need to allocate resources and guide junior investigators. And finally, an understanding of the methods will also enhance clinicians’ ability to critically read and understand studies on which practice decisions might be based.

Importance of Perioperative Glycemic Control in General Surgery A Report From the Surgical Care and Outcomes Assessment Program

Article

Jan 2013
ANN SURG

: To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. : There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. : The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. : Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. : Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Practice Advisory for Preanesthesia Evaluation An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation

Article

Mar 2012
ANESTHESIOLOGY

PRACTICE Advisories are systematically developed reports that are intended to assist decision-making in areas of patient care. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Practice Advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements, and their use cannot guarantee any specific outcome. They may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Practice Advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice Advisories are subject to periodic update or revision as warranted by the evolution of medical knowledge, technology, and practice. This document updates the "Practice Advisory for Preanesthesia Evaluation: A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation," adopted by the ASA in 2001 and published in 2002.

Risk factors associated with surgical site infection in 30 491 primary total hip replacements

Article

Oct 2012

We examined patient and surgical factors associated with deep surgical site infection (SSI) following total hip replacement (THR) in a large integrated healthcare system. A retrospective review of a cohort of primary THRs performed between 2001 and 2009 was conducted. Patient characteristics, surgical details, surgeon and hospital volumes, and SSIs were identified using the Kaiser Permanente Total Joint Replacement Registry (TJRR). Proportional-hazard regression models were used to assess risk factors for SSI. The study cohort consisted of 30 491 THRs, of which 17 474 (57%) were performed on women. The mean age of the patients in the whole series was 65.5 years (13 to 97; sd 11.8) and the mean body mass index was 29.3 kg/m ² (15 to 67; sd 5.9). The incidence of SSI was 0.51% (155 of 30 491). Patient factors associated with SSI included female gender, obesity, and American Society of Anesthesiologists (ASA) score ≥ 3. Age, diagnosis, diabetes and race were not associated with SSI. The only surgical factor associated with SSI was a bilateral procedure. Surgeon and hospital volumes, use of antibiotic-laden cement, fixation method, laminar flow, body exhaust suits, surgical approach and fellowship training were not associated with risk of SSI. A comprehensive infection surveillance system, combined with a TJRR, identified patient and surgical factors associated with SSI. Obesity and chronic medical conditions should be addressed prior to THR. The finding of increased SSI risk with bilateral THR requires further investigation.

Fast track surgery accelerates the recovery of postoperative insulin sensitivity

Article

Sep 2012

Few clinical studies or randomized clinical trial results have reported the impact of fast track surgery on postoperative insulin sensitivity. This study aimed to investigate the effects of fast track surgery on postoperative insulin sensitivity in patients undergoing elective open colorectal resection. Controlled, randomized clinical trial was conducted from November 2008 to January 2009 with one-month post-discharge follow-up. Seventy patients with colorectal carcinoma requiring colorectal resection were randomized into two groups: a fast track group (35 cases) and a conventional care group (35 cases). All included patients received elective open colorectal resection with combined tracheal intubation and general anesthesia. Clinical parameters (complication rates, return of gastrointestinal function and postoperative length of stay), stress index and insulin sensitivity were evaluated in both groups perioperatively. Sixty-two patients finally completed the study, 32 cases in the fast-track group and 30 cases in the conventional care group. Our findings revealed a significantly faster recovery of postoperative insulin sensitivity on postoperative day 7 in the fast-track group than that in the conventional care group. We also found a significantly shorter length of postoperative stay and a significantly faster return of gastrointestinal function in patients undergoing fast-track rehabilitation. Fast track surgery accelerates the recovery of postoperative insulin sensitivity in elective surgery for colorectal carcinoma with a shorter length of postoperative hospital stay.

Risk of Acute Myocardial Infarction in Patients With Total Hip or Knee Replacement

Article

Jul 2012

Arthur W Wallace

Lalmohamed et al1 used epidemiologic analysis to test the association between total hip replacement (THR) or total knee replacement (TKR) and acute myocardial infarction (AMI). Not surprisingly, during the first 2 postoperative weeks, the risk of AMI was elevated in both populations of patients undergoing THR or TKR. The risk was elevated for 6 weeks in patients undergoing THR but only for 2 weeks in those undergoing TKR. It has been previously established that patients undergoing surgical procedures have an increased risk of MI.1 The risk factors for perioperative cardiac morbidity and mortality have been established for many years, and although different studies2,3 find slightly different risk factors, there is remarkable consistency over time: age older than 60 years, coronary artery disease, peripheral vascular disease, congestive heart failure, recent MI, and the standard risk factors for coronary artery disease, including diabetes mellitus, hypertension, smoking, and hyperlipidemia. Occasionally, an investigator will suggest that one risk factor or another is no longer important, such as MI in the last 30 days, but subsequent studies will identify once again that recent MI, MI in the last 6 months, or MI in the last year remains a risk factor for subsequent MI. Epidemiologic studies are limited by the population of patients in the database. If no one performs elective surgery on a patient within 30 days of an AMI, then that variable will not be significant in epidemiologic analysis. Recent MI is still a risk factor for cardiac morbidity; it simply is not a significant risk factor identified in the study because there are no patients with that risk profile in the database. Failure to demonstrate that a risk factor is significant does not imply the risk factor is not still a clinical issue; it simply implies one could not demonstrate the effect with the database. Infrequently, a new perioperative risk factor is identified, such as erectile dysfunction.4 It is highly likely that these “new” risk factors are caused by peripheral vascular disease, which is highly associated with coronary artery disease rather than being a new independent perioperative risk factor.

Obesity, Diabetes, and Preoperative Hyperglycemia as Predictors of Periprosthetic Joint Infection: A Single-Center Analysis of 7181 Primary Hip and Knee Replacements for Osteoarthritis

Article

Jul 2012
J BONE JOINT SURG AM

Diabetes and obesity are common in patients undergoing joint replacement. Studies analyzing the effects of diabetes and obesity on the occurrence of periprosthetic joint infection have yielded contradictory results, and the combined effects of these conditions are not known. The one-year incidence of periprosthetic joint infections was analyzed in a single-center series of 7181 primary hip and knee replacements (unilateral and simultaneous bilateral) performed between 2002 and 2008 to treat osteoarthritis. The data regarding periprosthetic joint infection (defined according to Centers for Disease Control and Prevention criteria) were collected from the hospital infection register and were based on prospective, active surveillance. Patients diagnosed with diabetes were identified from the registers of the Social Insurance Institution of Finland. The odds ratios (ORs) for infection and the accompanying 95% confidence intervals (CIs) were calculated with use of binary logistic regression with adjustment for age, sex, American Society of Anesthesiologists risk score, arthroplasty site, body mass index, and diabetic status. Fifty-two periprosthetic joint infections occurred during the first postoperative year (0.72%; 95% CI, 0.55% to 0.95%). The infection rate increased from 0.37% (95% CI, 0.15% to 0.96%) in patients with a normal body mass index to 4.66% (95% CI, 2.47% to 8.62%) in the morbidly obese group (adjusted OR, 6.4; 95% CI, 1.7 to 24.6). Diabetes more than doubled the periprosthetic joint infection risk independent of obesity (adjusted OR, 2.3; 95% CI, 1.1 to 4.7). The infection rate was highest in morbidly obese patients with diabetes; this group contained fifty-one patients and periprosthetic infection developed in five (9.8%; 95% CI, 4.26% to 20.98%). In patients without a diagnosis of diabetes at the time of the surgery, there was a trend toward a higher infection rate in association with a preoperative glucose level of ≥6.9 mmol/L (124 mg/dL) compared with <6.9 mmol/L. The infection rate was 1.15% (95% CI, 0.56% to 2.35%) in the former group compared with 0.28% (95% CI, 0.15% to 0.53%) in the latter, and the adjusted OR was 3.3 (95% CI, 0.96 to 11.0). The type of diabetes medication was not associated with the infection rate. Diabetes and morbid obesity increased the risk of periprosthetic joint infection following primary hip and knee replacement. The benefits of joint replacement should be carefully weighed against the incidence of postoperative infection, especially in morbidly obese patients. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Validity of Patient-Reported Comorbidities Before Total Knee and Hip Arthroplasty in Patients Older Than 65 years

Article

Jul 2012

Obtaining preoperative medical histories in elderly patients can be challenging, and tools have been developed to aid in history gathering. The purpose of this study is to determine the agreement between patient- and physician-reported histories before total knee or hip arthroplasty. Three hundred eighty-two patients older than 65 years completed a preoperative morbidity assessment form preoperatively. Sensitivity, specificity, κ, and agreement were calculated for each dichotomous response. Diabetes (κ = 0.77) and lung disease (κ = 0.68) had substantial agreement. Fourteen comorbidities ranged from slight to moderate agreement. Osteoarthritis and peripheral vascular disease had no agreement. These results highlight the incongruence between patient- and physician-reported comorbidities and emphasizes the need for detailed histories by health care professionals for medically complicated elderly patients preoperatively.

Relationship of Hyperglycemia and Surgical-Site Infection in Orthopaedic Surgery

Article

Jul 2012
J BONE JOINT SURG AM

The impact of perioperative hyperglycemia in orthopaedic surgery is not well defined. We hypothesized that hyperglycemia is an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes at hospital admission. Patients eighteen years of age or older with isolated orthopaedic injuries requiring acute operative intervention were studied. Patients with diabetes, injuries to other body systems, a history of corticosteroid use, or admission to the intensive care unit were excluded. Blood glucose values were obtained, and hyperglycemia was defined in two ways. First, patients with two or more blood glucose levels of ≥200 mg/dL were identified. Second, the hyperglycemic index, a validated measure of overall glucose control during hospitalization, was calculated for each patient. A hyperglycemic index of ≥1.76 (equivalent to ≥140 mg/dL) was considered to indicate hyperglycemia. The primary outcome was thirty-day surgical-site infection. Multivariable logistic regression models evaluating the effect of the markers of hyperglycemia, after controlling for open fractures, were constructed. Seven hundred and ninety patients were identified. There were 268 open fractures (33.9%). Twenty-one thirty-day surgical-site infections (2.7%) were recorded. Age, race, comorbidities, injury severity, and blood transfusion were not associated with the primary outcome. Of the 790 patients, 294 (37.2%) had more than one glucose value of ≥200 mg/dL. This factor was associated with thirty-day surgical-site infection, with thirteen (4.4%) of the 294 patients with that indication of hyperglycemia having a surgical-site infection versus eight (1.6%) of the 496 patients without more than one glucose value of ≥200 mg/dL (p = 0.02). One hundred and thirty-four (17.0%) of the 790 patients had a hyperglycemic index of ≥1.76, and this was also associated was thirty-day surgical-site infection (ten [7.5%] of 134 versus eleven [1.7%] of 656; p < 0.001). Multivariable logistic regression models demonstrated that two or more blood glucose levels of ≥200 mg/dL was a risk factor for thirty-day surgical-site infection (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.1 to 6.7) after adjustment for open fractures (OR: 3.2, 95% CI: 1.3 to 7.8). A second model demonstrated that a hyperglycemic index of ≥1.76 was an independent risk factor for surgical-site infection (OR: 4.9, 95% CI: 2.0 to 11.8) after controlling for open fractures (OR: 3.3, 95% CI: 1.4 to 8.3). Hyperglycemia was an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes.

Trends in In-Hospital Major Morbidity and Mortality After Total Joint Arthroplasty: United States 1998-2008

Article

May 2012

The use of total joint arthroplasties is increasing worldwide. In this work we aim to elucidate recent trends in demographics and perioperative outcomes of patients undergoing total hip (THA) or total knee arthroplasty (TKA). Data from the US Nationwide Impatient Sample between 1998 and 2008 were gathered for primary THAs and TKAs. Trends in patient age, comorbidity burden, length of hospitalization, frequency of major perioperative complications, and in-hospital mortality were analyzed. In-hospital outcomes were reported as events per 1000 inpatient days to account for changes in length of hospitalization over time. Deyo index, discharge status, and the interaction effect of time and discharge status were included in the adjusted trend analysis for morbidity. Between 1998 and 2008, the average age of patients undergoing TKA and THA decreased by 2 to 3 years (P < 0.001). The average length of stay decreased by approximately 1 day over the time interval studied (P < 0.001). The percentage of patients being discharged home declined from 29.7% to 25.4% after TKA and from 29.3% to 24.2% after THA, in favor of dispositions to long- and short-term care facilities (P < 0.0001). Comorbidity burden as measured by the Deyo comorbidity index increased by 35% and 30% for TKA and THA patients, respectively (P < 0.0001). After TKA, there was an increase in the incidence of the following major complications: pulmonary embolism (coefficient estimate [CE] 0.069; 95% confidence interval [CI], 0.059-0.079; P < 0.0001), sepsis (CE 0.034; 95% CI, 0.014-0.054; P = 0.001), nonmyocardial infarction cardiac complications (CE 0.038; 95% CI, 0.035-0.041; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.031-0.047; P < 0.0001). After THA, there was an increase in the incidence of the following major complications: pulmonary embolism (CE 0.031; 95% CI, 0.012-0.049; P = 0.001), sepsis (CE 0.060; 95% CI, 0.039-0.081; P < 0.0001), nonmyocardial infarction cardiac complications (CE 0.040; 95% CI, 0.036-0.043; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.029-0.048). In-hospital mortality declined after both TKA (CE -0.059; 95% CI, -0.077 to -0.040; P < 0.0001) and THA (CE -0.068; 95% CI, -0.086 to -0.051; P < 0.0001). Between 1998 and 2008, trends show increases in several major in-hospital complications after THA and TKA, including pulmonary embolism, sepsis, nonmyocardial infarction cardiac complications, and pneumonia. Despite the increase in complications, declining in-hospital mortality was noted over this period.

Assessing Readmission Databases: How Reliable Is the Information?

Article

May 2012

Databases are being used to shape health care policy. However, the reliability of coding information entered into the databases may be difficult to validate. In this study, we assess readmission data from an institutional database that identified 1515 readmissions (708 patients) after total hip or total knee arthroplasty during a 5-year interval. After exclusions, 223 readmissions (190 patients) underwent medical record review. Bleeding, wound-related, and arthroplasty-related complications constituted most (62.8%) of readmissions. Bleeding and wound complications were nearly 6 times more frequently associated with readmission than venous thromboembolism events. On secondary review, there was discordance between the diagnosis obtained by a surgeon reviewer and coding for diagnoses consistent with periprosthetic infection (996.66, 77, 78, and 998.59) in 70% of cases. The findings of our study raise questions regarding the validity of accepting information obtained from larger databases without closer scrutiny.

Jonathan E. Rhoads Lecture 2011

Article

May 2012

Olle Ljungqvist

This lecture reviews the current understanding of how insulin resistance, as a marker of the metabolic stress, is involved in recovery after major surgery. Insulin resistance develops as a graded response related to the magnitude of the operation. It lasts for weeks after medium-size surgery and affects all parts of body metabolism. Although hyperglycemia develops, muscle and fat uptake is reduced and other non-insulin-sensitive cells have an increase in glucose uptake as a result of the elevated glucose levels. Reduced glucose uptake and storage in muscle along with loss of lean body mass help explain reduced muscle function that will impair mobilization. The increased uptake of glucose in non-insulin-sensitive cells is involved in the development of several of the most common postoperative complications, including infections and cardiovascular problems. Many of the perioperative treatments in use are outdated, and modern care involves a multimodal approach with several treatments, such as preoperative carbohydrate treatment instead of overnight fasting, continuous epidural anesthesia for postoperative pain care, early feeding, and mobilization, all of which affect insulin by reducing the stress and enhancing recovery. Most of the previous mandatory catabolic responses to surgery can be avoided, resulting in substantially faster recovery and fewer complications. Methods to implement these modern treatments have been developed and used in Europe, resulting in improved care and shorter length of stay.

Diabetes Mellitus, Hemoglobin A1C, and the Incidence of Total Joint Arthroplasty Infection

Article

Nov 2011

Patients with diabetes have a higher incidence of infection after total joint arthroplasty (TJA) than patients without diabetes. Hemoglobin A1c (HbA1c) levels are a marker for blood glucose control in diabetic patients. A total of 3468 patients underwent 4241 primary or revision total hip arthroplasty or total knee arthroplasty at one institution. Hemoglobin A1c levels were examined to evaluate if there was a correlation between the control of HbA1c and infection after TJA. There were a total of 46 infections (28 deep and 18 superficial [9 cellulitis and 9 operative abscesses]). Twelve (3.43%) occurred in diabetic patients (n = 350; 8.3%) and 34 (0.87%) in nondiabetic patients (n = 3891; 91.7%) (P < .001). There were 9 deep (2.6%) infections in diabetic patients and 19 (0.49%) in nondiabetic patients. In noninfected, diabetic patients, HbA1c level ranged from 4.7% to 15.1% (mean, 6.92%). In infected diabetic patients, HbA1c level ranged from 5.1% to 11.7% (mean, 7.2%) (P < .445). The average HbA1c level in patients with diabetes was 6.93%. Diabetic patients have a significantly higher risk for infection after TJA. Hemoglobin A1c levels are not reliable for predicting the risk of infection after TJA.

Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009: From research to implementation

Article

Sep 2011
ARCH ORTHOP TRAUM SU

Fast-track surgery is the combination of optimized clinical and organizational factors aiming at reducing convalescence and perioperative morbidity including the functional recovery resulting in reduced hospitalization. As the previous nationwide studies have demonstrated substantial variations in length of stay (LOS) following standardized operations such as total hip and knee arthroplasty (THA and TKA), this nationwide study was undertaken to evaluate the implementation process of fast-track THA and TKA in Denmark. All hospitals in Denmark report to the National Patient Registry, linking the type of surgery and LOS with a unique individual social security number. This study is based on primary THA and TKA from a 5.5 million population from 2000 to the end of 2009. The number of performed primary unilateral THA and TKA has increased from around 7,200 in 2000 to 13,800 in 2009 with a concomitant reduction in LOS from median 10-11 days in 2000 to 4 days in 2009. Fast-track surgery has been successfully implemented in the orthopedic departments in Denmark through a multi-disciplinary educational and multi-institutional effort. These implementation principles may be transferred to other countries and other specialties.

Evidence-Based Medicine in Surgery

Article

Jul 2011
J Am Med Assoc

The Institute of Medicine defines the quality of health care as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 Yet for much of the 20th century, the knowledge base for surgical practice was not influenced by systematic evidence, but rather by expert opinion and collective experience. Early attempts to scientifically measure and improve surgical quality, such as Codman's “end result idea”2 in the early 1900s that sought to collect and analyze surgical outcomes, met intense resistance. Fortunately, evidence-based medicine in surgery has now been thoroughly accepted; sophisticated researchers are applying a variety of study designs and methodological techniques to answer an expansive number of important clinical questions. Nonetheless, despite the diversity of high-quality research being performed, many continue to contend that the randomized controlled trial (RCT) is the only valid source of evidence, whereas observational research is assumed to be only preliminary work. The need and legitimacy of both experimental and observational studies deserve to be highlighted.

Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery

Article

Aug 2008
ANN SURG

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. To assess, synthesize, and discuss implementation of "fast-track" recovery programs. Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

Why is the surgical high-risk patient still at risk?

Article

Mar 2011
BRIT J ANAESTH

Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery

Article

Jun 2011

Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] -3.92 to -1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36-0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14-1.43) when compared with patients undergoing traditional care. Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.

The Effect of Diabetes Mellitus on Surgical Site Infections after Colorectal and Noncolorectal General Surgical Operations

Article

Jul 2010
AM SURGEON

Patients undergoing colorectal surgery (CRS) are known to be at increased risk of surgical site infection (SSI). We assessed the effect of diabetes and other risk factors on SSI in patients undergoing CRS and patients undergoing general surgery (GS). American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File from 2005 to 2006 was used. Chi2 tests, t tests, and logistic regression were used to assess the risk factors. Of the 129,909 study patients 10.1 per cent were patients undergoing CRS. The incidence of SSI in patients undergoing CRS was 3.8 times higher (95% CI, 3.6-4.1) than in patients undergoing GS. The incidence of SSI was higher in diabetics than nondiabetics in patients undergoing CRS (15.4 vs. 11.0%, P < 0.001) and patients undergoing GS (5.3 vs. 3.1%, P < 0.001). The significant univariate predictors of SSI for patients undergoing GS and patients undergoing CRS were: males, American Society of Anesthesiologists (ASA) class, diabetes emergency surgery, operation time, and greater than 2 units of intraoperative red blood cell transfusion. For patients undergoing GS, increasing age was also significant. After multivariate adjustment, significant predictors of SSI for patients undergoing GS and patients undergoing CRS were: male gender, diabetes, ASA class, emergency surgery, and operation time. For patients undergoing GS, age also remained significant. Among patients undergoing CRS, insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) were 1.32 (P < 0.05) times more likely than nondiabetics to develop SSI. Among patients undergoing GS, only IDDM (OR, 1.39; P < 0.001) were at increased risk. In this large hospital-based study, patients undergoing CRS were three times more likely to get SSI than patients undergoing GS. Diabetic patients with CRS (IDDM and NIDDM) and patients undergoing GS (IDDM) were at increased risk of SSI compared with nondiabetics. More intense glycemic control may reduce SSI in patients undergoing CRS with diabetes.

Perioperative Management of Diabetes and Hyperglycemia in Patients Undergoing Orthopaedic Surgery

Article

Jul 2010

Persons with diabetes undergo more surgical procedures, have a higher perioperative risk of complications, and have longer hospital stays than do persons who do not have diabetes. Persons with diabetes are frequently overweight, have a high prevalence of cardiovascular risk factors, and are more likely to suffer from chronic musculoskeletal conditions and traumatic injuries that require orthopaedic attention. Surgery frequently disrupts usual diabetes management, requiring adjustments to the treatment regimen. Suboptimal perioperative glucose control may contribute to increased morbidity, and it aggravates concomitant illnesses. Many patients undergoing elective or urgent orthopaedic surgery may have unrecognized diabetes or may develop stress-related hyperglycemia in the hospital. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce glycemic excursions, and prevent hypoglycemia. Recent guidelines advocate evidence-based glucose targets in the inpatient setting, and regimens for intravenous and subcutaneous insulin are gaining in popularity. Individualized treatment should be based on the ambient level of glycemic control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered. Management by a multidisciplinary team and attention to discharge planning are key aspects of care during and after orthopaedic surgery.

Risk of revision of a total hip replacement in patients with diabetes mellitus A POPULATION-BASED FOLLOW UP STUDY

Article

Jul 2010

We have evaluated the extent to which diabetes affects the revision rate following total hip replacement (THR). Through the Danish Hip Arthroplasty Registry we identified all patients undergoing a primary THR (n = 57 575) between 1 January 1996 and 31 December 2005, of whom 3278 had diabetes. The presence of diabetes among these patients was identified through the Danish National Registry of Patients and the Danish National Drug Prescription Database. We estimated the relative risk for revision and the 95% confidence intervals for patients with diabetes compared to those without, adjusting for the confounding factors. Diabetes is associated with an increased risk of revision due to deep infection (relative risk = 1.45 (95% confidence interval 1.00 to 2.09), particularly in those with type 2 diabetes (relative risk = 1.49 (95% confidence interval 1.02 to 2.18)), those with diabetes for less than five years prior to THR (relative risk = 1.69 (95% confidence interval 1.24 to 2.32)), those with complications due to diabetes (relative risk = 2.11 (95% confidence interval 1.41 to 3.17)), and those with cardiovascular comorbidities prior to surgery (relative risk = 2.35 (95% confidence interval 1.39 to 3.98)). Patients and surgeons should be aware of the relatively elevated risk of revision due to deep infection following THR in diabetes particularly in those with insufficient control of their glucose level.

Care principles at four fast-track arthroplasty departments in Denmark

Article

Jul 2010
Dan Med Bull

The goal of this study was to describe the logistic and clinical set-up at four Danish arthroplasty departments offering fast-track surgery. Based on the National Patient Registry's information on patients who have undergone total hip and knee arthroplasty, four departments were chosen for evaluation in accordance with the following inclusion criteria: documented fast-track surgery with written care plans, a surgical volume of > 450 arthroplasties and short length of stay (LOS) (< 5 days). The mean LOS ranged from 2.8 to 3.9 days. Logistic features included homogeneous entities, regular staff, high level of continuity, preoperative information including intended LOS, admission on the day of surgery and functional discharge criteria. The clinical features were both intraoperative (spinal anaesthesia, local infiltration analgesia, plans for fluid therapy, small standard incisions, no drains, compression bandages and cooling) and postoperative (deep venous thrombosis prophylaxis starting 6-8 hours postoperatively, multimodal opioid-sparing analgesia, early mobilisation and discharge when functional criteria were met) facilitating early rehabilitation and discharge. The logistic set-up at the four departments was almost identical. The basic care prerequisites to pooling the patients from these four departments were in place. Future studies will include outcomes as well as safety aspects of this set-up.

Glucose Measurement in the Operating Room: More Complicated than It Seems

Article

Feb 2010

Abnormalities of blood glucose are common in patients undergoing surgery, and in recent years there has been considerable interest in tight control of glucose in the perioperative period. Implementation of any regime of close glycemic control requires more frequent measurement of blood glucose, a function for which small, inexpensive, and rapidly responding point-of-care devices might seem highly suitable. However, what is not well understood by many anesthesiologists and other staff caring for patients in the perioperative period is the lack of accuracy of home glucose meters that were designed for self-monitoring of blood glucose by patients. These devices have been remarketed to hospitals without appropriate additional testing and without an appropriate regulatory framework. Clinicians who are accustomed to the high level of accuracy of glucose measurement by a central laboratory device or by an automated blood gas analyzer may be unaware of the potential for harmful clinical errors that are caused by the inaccuracy exhibited by many self-monitoring of blood glucose devices, especially in the hypoglycemic range. Knowledge of the limitations of these meters is essential for the perioperative physician to minimize the possibility of a harmful measurement error. In this article, we will highlight these areas of interest and review the indications, technology, accuracy, and regulation of glucose measurement devices used in the perioperative setting.

Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients

Article

May 2010

It is known that cardiac surgical patients with diabetes have greater peri-operative mortality and morbidity when compared with nondiabetic patients; the rate of adverse events in other surgery subspecialties has been only investigated minimally. The aim of this study was to test the magnitude of association between overt diabetes mellitus and postoperative complications across a spectrum of noncardiac surgical patients. Prospective outcome data registries describing 1,343 data sets from a spectrum of surgical subspecialties were examined to establish the prevalence of diagnosed diabetes, the incidence of intra- and postoperative complications, and the difference in proportion of morbidity between diabetic versus nondiabetic patients. There was a significant difference in overall morbidity between diabetic and nondiabetic patients with a 2.0 and 1.6 times increased morbidity risk in known diabetic patients with and without malignancy, respectively. Known diabetes was related to the number of postoperative complications in noncardiovascular patients. This study quantified the association between known diabetes and the occurrence of complications during recovery after a spectrum of noncardiac surgery. Because of a high prevalence of prediabetic and undiagnosed conditions, the strength of associations between glucose dysregulation and operative outcomes may be even greater than we report.

Severinsen MT, Kristensen SR, Overvad K, Dethlefsen C, Tjonneland A, Johnsen SPVenous thromboembolism discharge diagnoses in the Danish National Patient Registry should be used with caution. J Clin Epidemiol 63(2): 223-228

Article

Aug 2009

We validated discharge diagnoses of venous thromboembolism (VTE) in the Danish National Patient Registry. We identified all first-time VTE discharge diagnoses in the Danish National Patient Registry among participants of the Danish cohort study "Diet, Cancer, and Health", in the period from 1994 to 2006. Medical records were retrieved and VTE diagnoses were verified by one of the authors using a standard protocol. The positive predictive value (PPV) of a discharge diagnosis of VTE was calculated as percent of registry diagnoses with the corresponding true diagnosis in the chart among all registry diagnoses. We retrieved medical records from 1,100 of 1,135 participants (96.9%) registered with a discharge diagnosis of VTE; 626 diagnoses were confirmed and 17 were considered probable. The PPV of diagnoses coded at wards was 75.0% (95% confidence interval: 71.9, 77.9). Diagnoses from emergency departments were not valid. The PPV varied by type of VTE (deep venous thrombosis and pulmonary embolism), type of diagnosis (primary or secondary), and sex. Data on VTE obtained from administrative registries are a valuable source of information but should be used with caution in medical research.

The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty

Article

Aug 2009
J BONE JOINT SURG AM

As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital peri-operative complications following lower extremity total joint arthroplasty. From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-I and Type-II diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities. Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001). Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.

Surgical Treatment of Early Wound Complications After Primary Total Knee Arthroplasty

Article

Jan 2009
J BONE JOINT SURG AM

Wound-healing problems are a known complication after primary total knee arthroplasty. However, little is known about the clinical outcomes for patients who require surgical treatment of these early wound-healing problems. The purpose of the present study was to determine the incidence, risk factors, and long-term sequelae of early wound complications requiring surgical treatment. The total joint registry at our institution was reviewed for the period from 1981 to 2004. All knees with early wound complications necessitating surgical treatment within thirty days after the index total knee arthroplasty were identified. The cumulative probabilities for the later development of deep infection and major subsequent surgery were determined. A case-control study in which these patients were matched with an equal number of controls was performed to attempt to identify risk factors for the development of early superficial wound complications requiring surgical intervention. From 1981 to 2004, 17,784 primary total knee arthroplasties were performed at our institution. Fifty-nine knees were identified as having early wound complications necessitating surgical treatment within thirty days after the index arthroplasty, for a rate of return to surgery of 0.33%. For knees with early surgical treatment of wound complications, the two-year cumulative probabilities of major subsequent surgery (component resection, muscle flap coverage, or amputation) and deep infection were 5.3% and 6.0%, respectively. In contrast, for knees without early surgical intervention for the treatment of wound complications, the two-year cumulative probabilities were 0.6% and 0.8%, respectively (p < 0.001 for both comparisons). A history of diabetes mellitus was identified as being significantly associated with the development of early wound complications requiring surgical intervention. Patients requiring early surgical treatment for wound-healing problems after primary total knee arthroplasty are at significantly increased risk for further complications, including deep infection and/or major subsequent surgery, specifically, resection arthroplasty, amputation, or muscle flap coverage. These results emphasize the importance of obtaining primary wound-healing after total knee arthroplasty.

The Impact of Diabetes on Perioperative Patient Outcomes After Total Hip and Total Knee Arthroplasty in the United States

Article

Oct 2008

The purpose of this study was to determine whether patients with diabetes mellitus (DM) have a higher likelihood of immediate, inpatient complications following primary and revision total hip (THA) and total knee arthroplasty (TKA) than patients without DM. From 1988 to 2003, the Nationwide Inpatient Sample identified 751340 primary or revision THA or TKA patients. 64262 (8.55%) had DM. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed using bivariate and multivariate analyses with logistic regression modeling. Diabetic patients had fewer routine discharges and higher inflation-adjusted hospital charges for all procedures. Although complications were not uniformly increased, diabetic patients had significantly increased odds of pneumonia, stroke, and transfusion (P < .001) after primary arthroplasty. This analysis of a large patient database indicates clinically relevant information for patients and surgeons, suggesting that patients undergoing THA and TKA demonstrate more complications and utilize more resources if they have the comorbidity of DM level II evidence.

Confidence intervals for the number needed to treat

Article

Dec 1998

Douglas Altman

The number needed to treat (NNT) is a useful way of reporting the results of randomised controlled trials.1 In a trial comparing a new treatment with a standard one, the number needed to treat is the estimated number of patients who need to be treated with the new treatment rather than the standard treatment for one additional patient to benefit. It can be obtained for any trial that has reported a binary outcome. ### Summary points The number needed to treat is a useful way of reporting results of randomised clinical trials When the difference between the two treatments is not statistically significant, the confidence interval for the number needed to treat is difficult to describe Sensible confidence intervals can always be constructed for the number needed to treat Confidence intervals should be quoted whenever a number needed to treat value is given Trials with binary end points yield a proportion of patients in each group with the outcome of interest. When the outcome event is an adverse one, the difference between the proportions with the outcome in the new treatment (pN) and standard treatment (pS) groups is called the absolute risk reduction (ARR=pN−pS). The number needed to treat is simply the reciprocal of the absolute risk difference, or 1/ARR (or 100/ARR if percentages are used rather than proportions). A large treatment effect, in the absolute scale, leads to a small number needed to treat. A treatment that will lead to one saved life for every 10 patients treated is clearly better than a competing treatment that saves one life for every 50 treated. Note that when there is no treatment effect the absolute risk reduction is zero and the number needed to treat is infinite. As we will see below, this causes problems. As with other …

The Danish National Hospital Register. A Valuable Source of Data for Modern Health Sciences

Article

Jul 1999
DAN MED BULL

The Danish National Hospital Register (LPR) has collected nationwide data on all somatic hospital admissions since 1977, and since 1995 data on outpatients and emergency patients have been included as well. Numerous research projects have been undertaken in the national Danish context as well as in collaboration with international teams, and the LPR is truly a valuable source of data for health sciences, especially in epidemiology, health services research and clinical research. Nearly complete registration of somatic hospital events in Denmark is combined with ideal conditions for longterm follow-up due to the existence of a national system of unique person identification in a population of relative demographic stability. Examples of studies are provided for illustration within three main areas: I: Using LPR for surveillance of the occurrence of diseases and of surgical procedures, II: Using the Register as a sampling frame for longitudinal population based and clinical research, and III: Using the Register as a data source for monitoring outcomes. Data available from the Register as well as studies of the validity of the data are mentioned, and it is described how researchers may get access to the Register. The Danish National Hospital Register is well suited to contribute to international comparative studies with relevance for evidence-based medicine.

The prevalence of diabetes in Denmark. Development of a method for a registry-based assessment

Article

Aug 2003
Ugeskr Laeger

The prevalence of diabetes in Denmark is unknown. The purpose of the present article was to describe the possibilities of developing a method to identify individuals with diagnosed diabetes in Denmark on the basis of existing national registers. Record linkage of data from The Danish National Hospital Register, The Danish National Health Service Register and The Register of Medicinal Product Statistics. A minimum of 130,000 individuals in Denmark are estimated to have diabetes as on December 31, 1999. The possibility of developing a monitoring programme from existing data in registers seems to be present. If a validated monitoring programme is developed, this can not only be used to estimate the prevalence of diabetes, but also for a continuous monitoring of diabetes-related services.

Rising prevalence of diabetes: Evidence from a Danish pharmaco-epidemiological database

Article

Sep 2003
LANCET

The prevalence of diabetes has increased worldwide. We have undertaken an epidemiological analysis of drug-treated diabetes in a well defined community. We present estimates of prevalence, incidence, and mortality of patients with such diabetes during 1993-, based on data for all 470000 people living in the county of Fyn, Denmark. Although prevalence increased (odds ratio: female, 1.026 [95% CI 1.020-1.032]; male, 1.041 [1.036-1.047]), mortality in those treated declined (rate ratio: female, 0.976 [95%CI 0.952-1.001]; male, 0.966 [0.943-0.990]). We did not identify a clear trend for incidence. Future research into the causes of rising diabetes prevalence should take this fall in mortality into account to avoid incorrect conclusions about the relation between western lifestyle and the growing number of diabetics.

Estimating adjusted NNT measures in logistic regression analysis

Article

Dec 2007

The number needed to treat (NNT) is a popular measure to describe the absolute effect of a new treatment compared with a standard treatment or placebo in clinical trials with binary outcome. For use of NNT measures in epidemiology to compare exposed and unexposed subjects, the terms 'number needed to be exposed' (NNE) and 'exposure impact number' (EIN) have been proposed. Additionally, in the framework of logistic regression a method was derived to perform point and interval estimation of NNT measures with adjustment for confounding by using the adjusted odds ratio (OR approach). In this paper, a new method is proposed which is based upon the average risk difference over the observed confounder values (ARD approach). A decision has to be made, whether the effect of allocating an exposure to unexposed persons or the effect of removing an exposure from exposed persons should be described. We use the term NNE for the first and the term EIN for the second situation. NNE is the average number of unexposed persons needed to be exposed to observe one extra case; EIN is the average number of exposed persons among one case can be attributed to the exposure. By means of simulations it is shown that the ARD approach is better than the OR approach in terms of bias and coverage probability, especially if the confounder distribution is wide. The proposed method is illustrated by application to data of a cohort study investigating the effect of smoking on coronary heart disease.

Postoperative Morbidity and Mortality in Type-2 Diabetics After Fast-Track Primary Total Hip and Knee Arthroplasty

Abstract

No full-text available

Recommended publications

Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty

Polyethylene in total knee arthroplasty: Where are we now?

Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current...

Peri-operative interventions producing better functional outcomes and enhanced recovery following to...