Elective Knee Arthroplasty Research Articles

Effect of the application of the “Patient blood management” programme on the approach to elective hip and knee arthroplasties

Background and objectivesThe “Patient Blood Management” (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals. Patients and methods702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analyzed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients’ computerized clinical histories. ResultsStages and transfusion rates were: Year 2011–2012, “Universal self-donation programme”: 62.4%; year 2013, “Optimization of preoperative haemoglobin and universal self-donation withdrawal”: 22.5%; year 2015, “Stopping the use of cell-savers and drains”: 13.2%; and year 2017, “Introduction of routine tranexamic acid”: 3.6%. A significant reduction in the transfusion rate and volume (p<0.001) and the average hospital stay (8–6 days) (p<0.001) was achieved. In multivariate models, transfused patients have a 0.5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR 0.44). ConclusionA simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay.

Efficacy of Preoperative Usage of Dexamethasone in Diabetic Patients Undergoing Total Hip or Knee Arthroplasty for Control of Nausea and Vomiting.

Dexamethasone has been used in surgical patients to decrease nausea, vomiting, and postoperative pain. However, it is not well studied how much dexamethasone complicates glucose control in diabetic patients and whether this leads to poor surgical outcomes. We analyzed 256 diabetic patients who underwent elective hip and knee arthroplasty and evaluated the groups that received dexamethasone intraoperatively (201 patients), those who received dexamethasone postoperatively (237 patients), and those who did not receive the steroid intraoperatively (55 patients) and postoperatively (19 patients). 256 diabetic patients were included in the study. The mean age of the group was 68.7 (SD ± 9-10) years. Patients were divided into 123 males (48%) and 133 females (52%). 174 (78%) patients had a total knee replacement operation, and 82 (32%) patients had total hip replacement operation. The mean hemoglobin A1c was 6.728 (SD ± 0.99). The mean ASA score was 2.86 (SD ± 0.38). 201 (78.5%) patients received preoperative or intraoperative dexamethasone, and 237 (92.6%) patients received it postoperatively. The mean blood glucose for all patients raised from 131.9 to 172.2 mg/dL (P = .012) postoperatively, 206.1 mg/dL in the first 24 hours, and 146.2 mg/dL (P = .39) in the second postoperative day. The change was significant in patients who had poorly controlled diabetes (P < .01) preoperatively. There was no significant difference in our study regarding dexamethasone use and effect on postoperative nausea (P = 1.0) and vomiting (P = .52). There was an improvement in pain scores in the patients who received dexamethasone postoperatively which was statistically significant (P = .054). Dexamethasone use in diabetic patients for control of postoperative nausea and vomiting in those undergoing elective total knee and hip arthroplasty had a negative impact on glycemic control specifically in those with poorly controlled diabetes and should be avoided.

Is Routine Hemoglobin Monitoring Necessary after Elective Hip and Knee Arthroplasty?

BackgroundMany orthopaedic units measure hemoglobin (Hb) levels after primary joint arthroplasty to identify patients with postoperative anemia. With the refinement of surgical techniques, blood loss in primary arthroplasty has decreased. The aim of this study was to investigate the postoperative Hb monitoring and transfusion practices in our own institution after elective hip or knee arthroplasty. MethodsWe conducted a retrospective audit of all patients who underwent elective total hip or knee arthroplasty in Galway University Hospital between March 1 and June 1, 2019. We recorded when they underwent postoperative Hb testing, whether or not they had a drop of Hb, which would indicate transfusion (<8 g/dL), and whether or not they were transfused. In patients who underwent transfusion, a chart review was performed to establish the presence of factors that would have triggered repeat Hb testing. ResultsOne hundred thirty-six patients underwent elective primary hip or knee arthroplasty in the period. All had a full blood count sent on the first postoperative day. None (0%) had a clinically significant (to < 8g/dL) postoperative Hb drop on day 1. Eighteen (13.2%) patients underwent repeat testing on day 2 or subsequently. Eight (5.9%) exhibited a drop in Hb to less than 8 g/dL, with a mean Hb drop of 4.26 (standard error of the mean ± 0.862, standard deviation ± 0.98), and 5 (3.7%) proceeded to undergo allogenic blood product transfusion. All 5 underwent documented indications for repeat Hb testing. ConclusionsThere is no evidence for performing routine Hb testing on day 1 after elective hip or knee arthroplasty. We recommend that postoperative Hb testing should only be carried out on patients with additional indications.

Patient-reported outcomes in patients undergoing elective arthroplasty: the PaRIS-IOR study

Abstract Background The number of hip and knee arthroplasties continues to rise worldwide. The Organization for Economic Cooperation and Development has launched the PaRIS Initiative for the systematic collection of Patient Reported Outcome Measures (PROMs) in patients undergoing elective hip and knee arthroplasty. The Rizzoli Orthopedic Institute (IOR) was selected as a pilot center for the Initiative (PaRIS-IOR study), because it hosts the Registry of Orthopedic Prosthetic Implants (RIPO). The objective of PaRIS-IOR study is to investigate the characteristics and temporal trend of PROMs in relation to the type of surgical intervention and patient profile. Here we report the preliminary results of the first study year. Methods The PaRIS-IOR is a prospective, single site, cohort study started on January 1st 2019 that consists of the administration of Euro Quality 5 Dimensions (EQ-5D), Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score Physical function Short-form (HOOS-PS, KOOS-PS) questionnaires to patients on the list for elective arthroplasty. Questionnaires data are linked with those routinely collected by the RIPO and regional administrative data, in order to track patients' medical history. Results The study population consists of 1,413 patients. Patients undergoing knee arthroplasty (n = 393) were older (68.4 vs 60.2 years; p &amp;lt; 0.001), and had a higher prevalence of obesity (41.6 vs 22.6%; p &amp;lt; 0.001) than patients undergoing hip arthroplasty (n = 1020). Female and obese patients reported a worse perceived health status both in the EQ-5D (p &amp;lt; 0.001) and in the HOOS-PS and KOOS-PS (p &amp;lt; 0.001). Among patients who underwent knee surgery, the younger ones reported a poorer perceived health in the general and the specific questionnaires. Conclusions The PaRIS-IOR study has potential important implications in targeting the factors affecting patient-reported functional outcomes and quality of life after joint arthroplasty. Key messages The PaRIS-IOR study underscores the poorer perception of health status in female and obese patients undergoing arthroplasty and in younger patients undergoing knee surgery. The routine adoption of PROMs may support surgeons in the management of patients undergoing hip and knee arthroplasty and policy-makers in improving healthcare quality in orthopedics.

Predictors of hyponatremia following elective primary unilateral knee arthroplasty at a tertiary centre: A retrospective observational cohort and predictive model

IntroductionHyponatremia is a common electrolyte disorder. This can be associated with nausea, disorientation and in more serious cases a decreased level of consciousness or neurological deficits. These symptoms may lead to increases in the cost of hospital care and significant morbidity. The purpose of this retrospective, observational cohort study is to investigate the impact of hyponatremia on patient and systems specific outcome measures in those undergoing elective, unilateral total knee arthroplasty (TKA) at two hospitals in Auckland, New Zealand over a twelve-month period. Materials and methodsPatients were stratified into two groups based on the presence or absence of post-operative hyponatremia (defined as a blood sodium of <135 mmol/L with a concurrent decrease of ≥5 mmol/L between the pre- and post-operative recordings). Outcomes collected included Quality of Recovery – 15 (QOR) scores, time to assisted mobilisation, discharge ICD-10 complication codes and hospital length of stay. ResultsDuring the study period 236 patients underwent surgery. Eighty-six (36.4%) patients met criteria for post-operative hyponatremia. This finding was associated with prolongation of the hospital length of stay (4.17 (3.26–5.18) versus 4.28 (3.31–5.45) days, p = 0.031) and a reduction in the QOR score on the second post-operative day (113.0 (99.5–126.5) versus 105.0 (94.0–118.0), p = 0.039). There was no difference in the time to assisted mobilisation. ConclusionsHyponatremia is a common finding following TKA. This abnormality is associated with small changes in patient specific outcome measures. These implications of these findings may become more significant in settings where same day or rapid discharge from hospital is targeted.

Polypharmacy After Elective Orthopaedic Surgery

Polypharmacy is common, especially among older patients. Polypharmacy can lead to adverse patient outcomes and increased healthcare costs. After elective hip or knee arthroplasty, several new medications are prescribed, which can contribute to polypharmacy, although these medications are necessary in the postoperative period. Although some instances of polypharmacy may be appropriate, many are not. Nurse practitioners play a vital role in identifying and preventing inappropriate polypharmacy in the postoperative period and can develop individualized therapy plans for each patient to provide safe medication use in patients. This would be beneficial in the orthopaedic surgery postoperative period because of the introduction of several new medications.

Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations

PurposeThe Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out.MethodsA panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey.ResultsThe guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement.ConclusionApart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

Recommendations for resuming elective hip and knee arthroplasty in the setting of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates Survey of Members

PurposeThe COVID-19 pandemic has disrupted the health care system around the entire globe. A consensus is needed about resuming total hip and knee procedures. The European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus statement on how the safe re-introduction of elective hip and knee arthroplasty should be undertaken.MethodsA prospective online survey was done among members of EHS and EKA. The survey consisted of 27 questions. It includes basic information on demographics and details the participant’s agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). Recommendations focussed on pre-operative, peri-operative, and post-operative handling of patients and precautions.ResultsA total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The participants were from 44 countries and 6 continents. Apart from adhering to National and Local Guidelines, the recommendations concerned how to make elective arthroplasty safe for patients and staff.ConclusionThe survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the first wave of the COVID-19 pandemic.

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations

PurposeTo plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections.MethodA systematic review was conducted using the terms “COVID-19” or “SARS-Cov-2” and “second wave”. No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations.ResultsOverall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family’s lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves.ConclusionsThe recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.

Protective Effects of Rocuronium Bromide on Ischemia-Reperfusion Injury in Skeletal Muscle Induced by Tourniquet in Patients Undergoing Elective Unilateral Total Knee Arthroplasty: A Prospective, Double Blind, Randomized, Controlled Study.

PurposeTo investigate the effects of different doses of rocuronium on ischemia-reperfusion injury in skeletal muscle induced by tourniquet in patients undergoing elective unilateral total knee arthroplasty.Patients and MethodsA total of 90 patients undergoing elective unilateral knee arthroplasty under general anesthesia combined with femoral nerve block were randomly divided into 3 groups: normal saline group (group S), rocuronium 0.6 mg/kg group (group L), and rocuronium 1.2 mg/kg group (group H). The primary outcome was the expression of dystrophin in skeletal muscle at 60 min after ischemia. Secondary outcomes included the concentration of malondialdehyde (MDA) and neuronal nitric oxide synthase (nNOS) in blood at 5 min and 30 min after reperfusion. In addition, thigh girth at 24 h and 48 h after operation, the leaving bed time, the incidence of tourniquet-related hypertension and short-term (3 days after operation) complications (nausea and vomiting, swelling, blister, wound infection) and long-term (3 months after operation) complications (joint instability, stiffness, nerve paralysis, pain) were recorded.Main ResultsThe expression of dystrophin in the rocuronium group was higher than that in group S after ischemia (P <0.05). The concentration of MDA in the rocuronium 1.2 mg/kg group was lower at 30 min after reperfusion (P < 0.05). There was no significant difference in nNOS among groups at each time point (P > 0.05). The change of thigh girth was the smallest in the rocuronium 1.2 mg/kg group after operation (P<0.05). The leaving bed time was significantly earlier after operation in the rocuronium group than that in group S (P <0.05).ConclusionRocuronium can protect skeletal muscle from ischemia-reperfusion injury induced by tourniquet. The mechanism may be related to the fact that rocuronium can reduce the loss of dystrophin in skeletal muscle and have the effects of anti-oxidation and anti-stress.Trial RegistrationThe study was registered at http://www.chictr.org.cn (ChiCTR1800019221, registered on 2018–10-31).

Role of OT in an Interdisciplinary Team Care Approach, Used to Rehabilitate Elective Hip and Knee Arthroplasties: A Systematic Review

Abstract Date Presented 03/26/20 This study is exploring the functional outcomes of OT interventions that are used within an interdisciplinary team to rehabilitate clients who underwent elective joint-replacement surgeries. This systematic review supports the inclusion of OT services within an interdisciplinary team for elective joint-replacement surgery and shows evidence that OT can improve functional outcomes, well-being, and rate of recovery. Primary Author and Speaker: Manisha Sheth Additional Authors and Speakers: Rose Simone, Bethany Shimoda, Dana Dalusung, Joeyann Peralta

Anti-rheumatic treatment and prosthetic joint infection: an observational study in 494 elective hip and knee arthroplasties

BackgroundSurgical site infections are more frequent among patients with rheumatic disease. To what extent this is related to immunosuppressive antirheumatic drugs is unclear, as is the value of discontinuing medication perioperatively. The aim of study was to assess the rate of surgical site infections after knee and hip replacement in patients with inflammatory joint disease, with an emphasis on periprosthetic joint infection, and to investigate the influence of treatment with disease-modifying antirheumatic drugs (DMARDs) in this regard.MethodsData were collected from 494 primary elective hip (51.4%) and knee arthroplasties, along with demographic and medication data. The primary outcome was surgical site infection during the first year after surgery.ResultsIn 78% (n = 385) of the cases the patient used 1 to 3 disease-modifying antirheumatic drugs perioperatively. Thirty-two percent (n = 157) of patients used a TNF-alpha inhibitor. The rate of surgical site infection was 3.8% (n = 19). The rate of periprosthetic joint infection was 1.4% (n = 7), all of which occurred after knee arthroplasty. Periprosthetic joint infection occurred in only 1 patient medicating perioperatively with a TNF-alpha inhibitor.ConclusionSurgical site infections were not associated with ongoing medication with disease-modifying antirheumatic drugs. Due to the low event rate this should be interpreted with caution, but our center will maintain its routine of continuing treatment with TNF-alpha inhibitors perioperatively.

Clinical and Budget Impact of Treating Preoperative Anemia in Major Orthopedic Surgery—A Retrospective Observational Study

BackgroundPreoperative anemia (POA) in elective surgery is associated with worse outcome. In this retrospective study, in elective hip and knee arthroplasties, the prevalence of POA and its associations with outcome were analyzed, followed by a model estimating the budget impact of screening and treatment of POA. MethodsAll elective hip/knee arthroplasties performed during the period 2016-2018 were included. Patients with normal hemoglobin and patients with POA (hemoglobin < 13.0 g/dL in men and <12.0 g/dL in women) were compared. Outcome measures were allogeneic blood transfusion (ABT), length of stay (LOS), complications, mortality, and costs. The budget impact of screening for POA and treatment with intravenous iron when relevant was modeled based on the results of the costs related to POA. ResultsIn 881 procedures, the prevalence of POA was 21.5%. POA independently predicted increased risks of ABT (odds ratio [OR]adj, 9.5 [confidence interval—CI, 6.4-13.9]), prolonged LOS (ORadj, 2.8 [CI, 1.8-4.2]), and was associated with increased complications (ORadj, 1.9 [CI, 0.7-4.9]) and mortality (ORadj, 3.2 [CI, 0.8-13.5]). POA resulted in increased costs per patient (P < .001). The budget impact model showed a cost reduction of 254 euros per patient based on the assumption that patients screened and treated for iron-deficient anemia would have the same outcome as non-POA. ConclusionThe prevalence of POA in elective orthopedic surgery in Sweden is at the same level as previously reported by others. Screening and treatment of POA would reduce costs based on less ABT and decreased LOS and may reduce complications in elective major orthopedic surgery.

Opioid Stewardship Program and Postoperative Adverse Events: A Difference-in-differences Cohort Study.

A 6-month opioid use educational program consisting of webinars on pain assessment, postoperative and multimodal pain opioid management, safer opioid use, and preventing addiction coupled with on-site coaching and monthly assessments reports was implemented in 31 hospitals. The authors hypothesized the intervention would measurably reduce and/or prevent opioid-related harm among adult hospitalized patients compared to 33 nonintervention hospitals. Outcomes were extracted from medical records for 12 months before and after the intervention start date. Opioid adverse events, evaluated by opioid overdose, wrong substance given or taken in error, naloxone administration, and acute postoperative respiratory failure causing prolonged ventilation were the primary outcomes. Opioid use in adult patients undergoing elective hip or knee arthroplasty or colorectal procedures was also assessed. Differences-in-differences were compared between intervention and nonintervention hospitals. Before the intervention, the incidence ± SD of opioid overdose, wrong substance given, or substance taken in error was 1 ± 0.5 per 10,000 discharges, and naloxone use was 117 ± 13 per 10,000 patients receiving opioids. The incidence of respiratory failure was 42 ± 10 per 10,000 surgical discharges. A difference-in-differences of -0.2 (99% CI, -1.1 to 0.6, P = 0.499) per 10,000 in opioid overdose, wrong substance given, or substance taken in error and -13.6 (99% CI, -29.0 to 0.0, P = 0.028) per 10,000 in respiratory failure was observed postintervention in the intervention hospitals; however, naloxone administration increased by 15.2 (99% CI, 3.8 to 30.0, P = 0.011) per 10,000. Average total daily opioid use, as well as the fraction of patients receiving daily opioid greater than 90 mg morphine equivalents was not different between the intervention and nonintervention hospitals. A 6-month opioid educational intervention did not reduce opioid adverse events or alter opioid use in hospitalized patients. The authors' findings suggest that despite opioid and multimodal analgesia awareness, limited-duration educational interventions do not substantially change the hospital use of opioid analgesics.

Pulmonary function decline in immediate postoperative period is not necessarily related to residual neuromuscular block

Previous studies have reported an association between the use of neuromuscular blocking (NMB) agents and postoperative pulmonary complications. Postoperative pulmonary function is a key indicator for postoperative pulmonary complications. Several sites can be used to assess depth and recovery from NMB. To investigate postoperative pulmonary function change in relation to train-of-four measurements at the adductor pollicis and corrugator supercilii muscles, and anaesthesia-related variables in orthopaedic patients undergoing hip or knee arthroplasty. Observational study. University hospital. Orthopaedic patients undergoing hip or knee arthroplasty. Postoperative pulmonary function tests in the postanaesthesia care unit. Patients scheduled for elective hip or knee arthroplasty received simultaneous corrugator supercilii and adductor pollicis measurements during anaesthesia conducted according to clinical standards. Forced expiratory volume in 1 s and forced vital capacity (FVC) were measured at the time of inclusion and postoperatively on the postanaesthesia care unit. Linear regression analysis was performed for association between risk factors and pulmonary function change. A total of 35 patients were included. After exclusions, 20 patients remained for final analysis. Corrugator supercilii showed earlier NMB recovery than adductor pollicis. FVC decreased significantly after surgery from 2.9 ± 1.0 to 2.3 ± 1.0 (P < 0.01) and forced expiratory volume in 1 s decreased from 2.3 ± 0.9 to 1.6 ± 0.8 l (P < 0.01). Patient age was the only factor significantly related to FVC decrease after surgery (P = 0.019) with a cut-off value of 65 years. Both corrugator supercilii and adductor pollicis failed to indicate recovery of pulmonary function after NMB. Age seems to be a risk factor for postoperative decline in pulmonary function. German Clinical Trials registry, DRKS-ID: DRKS00014305.

Effectiveness and safety of the use of antifibrinolytic agents in total-knee arthroplasty

Background:Antifibrinolytic agents have been successfully used to reduce blood transfusion demand in patients undergoing elective knee arthroplasty. The purpose of this study was to investigate different antifibrinolytic agents for patients undergoing total-knee arthroplasty (TKA).Methods:We searched the randomized controlled trials assessing the effect of antifibrinolytic agents on TKA in MEDLINE, PubMed, Embase, and the Cochrane Library. Participants are divided into antifibrinolytic agent group and control group under TKA. Double extraction technology is used and the quality of its methodology is evaluated before analysis. Outcomes analyzed included blood loss, number of blood transfusions, rates of blood transfusion, and deep vein thrombosis (DVT).Results:A total of 28 randomized controlled trials involving 1899 patients were included in this study. Compared with the control group, the antifibrinolytic agents group exhibited significantly reduced the amounts of total blood loss (weighted mean difference [WMD] with 95% confidence interval [CI]: −272.19, −338.25 to −206.4), postoperative blood loss (WMD with 95% CI: −102.83, −157.64 to −46.02), average units of blood transfusion (risk ratio with 95% CI: 0.7, 0.12 to 0.24), and average blood transfusion volumes (WMD with 95% CI: −1.34, −1.47 to −1,21). Antifibrinolytic agents significantly reduced the rate of blood transfusions and did not increase the occurrence risk of intraoperative blood loss and DVT. Several limitations should also be acknowledged such as the heterogeneity among the studies.Conclusion:The application of antifibrinolytic agents can significantly reduce blood loss and blood transfusion requirements. Additionally, these agents did not increase the risk of DVT in patients undergoing TKAs.

Patients' Experiences of Pain and Postoperative Nausea and Vomiting in the Early Postoperative Period After an Elective Knee Arthroplasty

PurposeThe aim of this study is to explore patients' experience of pain and postoperative nausea and vomiting (PONV) in the early postoperative period after knee arthroplasties. DesignThis is a retrospective cohort study with a quantitative approach. Data from patients registered in the Swedish Perioperative Registry were used. We used the Strenghtening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. MethodsData were collected from patients (N = 439) undergoing knee arthroplasties. The analysis was performed with descriptive and analytic statistics. FindingsThe findings indicate that women experienced significantly higher levels of pain than men and suffered significantly more often from PONV. However, the relationship of postoperative pain and PONV was not significant. There was also no significance for the relationship among postoperative pain, PONV, and age. ConclusionsCare needs to be sensitive to differences in experiencing pain and PONV depending on sex or gender bias, with a goal of increasing the equality in care.

After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.

The Effect of the COVID-19 Pandemic on Electively Scheduled Hip and Knee Arthroplasty Patients in the United States

BackgroundIn response to the COVID-19 pandemic, hospitals in the United States were recommended to stop performing elective procedures. This stoppage has led to the cancellation of a large number of hip and knee arthroplasties. The effect of this on patients’ physical mental and economic health is unknown. MethodsA survey was developed by the AAHKS Research Committee to assess pain, anxiety, physical function, and economic ability of patients to undergo a delayed operation. Six institutions conducted the survey to 360 patients who had to have elective hip and knee arthroplasty cancelled between March and July of 2020. ResultsPatients were most anxious about the uncertainty of when their operation could be rescheduled. Although 85% of patients understood and agreed with the public health measures to curb infections, almost 90% of patients plan to reschedule as soon as possible. Age and geographic region of the patients affected their anxiety. Younger patients were more likely to have financial concerns and concerns about job security. Patients in the Northeast were more concerned about catching COVID-19 during a future hospitalization. ConclusionsPatients suffering from the pain of hip and knee arthritis continue to struggle with pain from their end-stage disease. They have anxiety about the COVID-19 pandemic. Few patients feel they will be limited financially and 90% want to have surgery as soon as possible. Age and physical location of the patients affect their causes for anxiety around their future surgery.

Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis

BackgroundSevere gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors. MethodsWe included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs). ResultsAmong THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01). ConclusionRare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.