Orthopedic Ambulatory Surgery Research Articles

Effect of Trainee Level on Surgical Time and Postoperative Complications of Anterior Cruciate Ligament Reconstruction

The objective of this study was to investigate the association between trainee level and surgical time and postoperative complications of anterior cruciate ligament reconstruction (ACLR). A retrospective chart review of patients who underwent ACLR at an academic orthopaedic ambulatory surgery center collected demographic and clinical information, including the number of trainees present and trainee level. Unadjusted and adjusted regression analyses assessed the association between trainee number and level with surgical time (time from skin incision to closure) and postoperative complications. Of 799 patients in this study operated on by one of five academic sports surgeons, 87% had at least one trainee involved. The average surgical time overall was 93 ± 21 minutes and by trainee level was 99.7 (junior resident), 88.5 (senior residents), 96.6 (fellows), and 95.6 (no trainees). Trainee level was significantly associated with surgical time (P = 0.0008), with increased surgical time in cases involving fellows (0.0011). Fifteen complications (1.9%) were observed within 90 days of surgery. No notable risk factors of postoperative complications were identified. Resident trainee level does not have a notable effect on surgical time or postoperative complications for ACLR at an ambulatory surgery center, although cases involving fellows had longer surgical times. Trainee level was not associated with risk of postoperative complications.

Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center

Background: Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED). Purpose/Hypothesis: The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication. Study design: Case-control study; Level of evidence, 3. Methods: A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters. Results: A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care (P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery (P = .077). Conclusion: Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.

Postoperative Distress of Orthopedic Ambulatory Surgery Patients

Patients who undergo orthopedic ambulatory surgery have reported high levels of symptom distress during recovery at home. Content analysis of this qualitative descriptive study identified techniques of symptom management that effectively reduce postoperative symptom distress after orthopedic ambulatory surgery and provided insight into facilitators and barriers to postsurgery self-management. Focus groups consisted of 19 patients and caregivers recruited from a university orthopedic surgery office. The authors identified the common themes as distressing symptoms and consequences of surgery, management of symptoms, and self-management facilitators and barriers. Participants in our study noted the lack of continuity of care after discharge and wanted to know the realities of symptoms and receive more detailed information from care providers on how to self-manage symptoms. Nurses involved in the care of these patients should focus not only on short-term recovery, but on preparing patients to manage sustained recovery issues at home.

Cost impact of unexpected disposition after orthopedic ambulatory surgery associated with category of anesthesia provider

Study ObjectiveTo provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures. DesignA projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study. SettingAmbulatory and inpatient surgery. PatientsBase-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses. InterventionsNot applicable. MeasurementsMajor complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios. Main ResultsIn the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios. ConclusionsProvision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.

Factors influencing unexpected disposition after orthopedic ambulatory surgery

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

Primary Payer Status Is Associated With the Use of Nerve Block Placement for Ambulatory Orthopedic Surgery

Although more than 30 million patients in the United States undergo ambulatory surgery each year, it remains unclear what percentage of these patients receive a perioperative nerve block. We reviewed data from the 2006 National Survey of Ambulatory Surgery to determine the demographic, socioeconomic, geographic, and clinical factors associated with the likelihood of nerve block placement for ambulatory orthopedic surgery. The primary outcome of interest was the association between primary method of payment and likelihood of nerve block placement. In addition, we examined the association between type of surgical procedures, patient demographics, and hospital characteristics with the likelihood of receiving a nerve block. This cross-sectional study reviewed 6000 orthopedic anesthetics from the 2006 National Survey of Ambulatory Surgery data set, which accounted for more than 3.9 million orthopedic anesthetics when weighted. The primary outcome of this study addressed the likelihood of receiving a nerve block for orthopedic ambulatory surgery according to the patient's primary method of payment. Secondary end points included differences in demographics, surgical procedures, adverse effects, complications, recovery profile, anesthesia staffing model, and total perioperative charges in those with and without nerve block. Overall, 14.9% of anesthetics in this sample involved a peripheral nerve block. Length of time in postoperative recovery, total perioperative time, and total charges were less for those receiving nerve blocks. Patients were more likely to receive a nerve block if their procedures were performed in metropolitan service areas (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.19-2.91; P = 0.007) or in freestanding surgical facilities (OR, 2.27; 95% CI, 1.74-2.96; P < 0.0001) and if payment for their surgery was supported by government programs (OR, 2.5; 95% CI, 1.01-6.21; P = 0.048) or private insurance (OR, 2.62; 95% CI, 1.12-6.13; P = 0.03) versus self-pay or charity care. For patients receiving ambulatory orthopedic surgery in the United States, our results suggest that geographic and socioeconomic factors are associated with different likelihoods of perioperative peripheral nerve block placement.

Changes in Anesthesia-Related Factors in Ambulatory Knee and Shoulder Surgery

Analyses of existing nationally representative information on how changes in ambulatory orthopedic surgery have affected anesthesia practice over time are rare. We sought to characterize temporal changes in factors surrounding ambulatory orthopedic surgery and anesthesia. Data from the National Survey of Ambulatory Surgery for the years of 1996 and 2006 were analyzed. Entries indicating the performance of knee ligamentoplasty, meniscectomy, or shoulder arthroscopy were identified and included in the sample. Temporal changes in a number of variables associated with orthopedic ambulatory surgery were assessed, including (1) the number of procedures being performed, (2) patient and health care system-related demographics, and (3) anesthesia-related variables. Nationwide, the total number of ligamentoplasties, meniscectomies, and shoulder arthroscopies increased from 1996 to 2006 by 66% (n = 258,932 to n = 428,712), 51% (n = 456,698 to n = 690,164), and 349% (n = 93,105 to n = 418,188), respectively (P < 0.0001). Between 1996 and 2006, the use of peripheral nerve blocks increased from 0.6% to 9.8% for meniscectomies (P < 0.0001), from 1.5% to 13.7% for ligamentoplasties (P < 0.0001), and from 11.5% to 23.9% for shoulder arthroscopies (P < 0.0001), respectively. Neuraxial anesthesia utilization fell from 11.8% to 6.3% for meniscectomies (P < 0.0001) and 13.6% to 7.3% for ligamentoplasties (P < 0.0001) from 1996 to 2006, respectively. Substantial increases in the number of ambulatory knee and shoulder procedures occurred over time, relating to increased demand for anesthesia providers in this field. Trends toward increased use of peripheral nerve blocks may have to be considered by educators when preparing residents for practice.

The Rising Incidence of Acromioplasty

Acromioplasty is considered a technically simple procedure but has become controversial with regard to its indications and therapeutic value. Two complementary databases were used to ascertain the frequency of acromioplasty over a recent span of time. In Part A, the New York Statewide Planning and Research Cooperative System (SPARCS) ambulatory surgery database was searched from 1996 to 2006 to identify all ambulatory surgery acromioplasties as well as all orthopaedic ambulatory surgery procedures. In Part B, the American Board of Orthopaedic Surgery (ABOS) database was searched from 1999 to 2008 to identify all arthroscopic acromioplasties as well as all orthopaedic procedures. Part A revealed that in 1996 there were 5571 acromioplasties in New York State, representing a population incidence of 30.0 per 100,000. In 2006 there were 19,743 acromioplasties, representing a population incidence of 101.9 per 100,000. Over these eleven years, the volume of acromioplasties increased by 254.4%, compared with only a 78.3% increase in the volume of all orthopaedic ambulatory surgery procedures. In 2006, as compared with 1996, patients were 2.4 times more likely to have an acromioplasty compared with all other orthopaedic ambulatory procedures (p < 0.0001). Part B revealed that, in 1999, a mean of 2.6 arthroscopic acromioplasties were reported per candidate for Board certification. In 2008 a mean of 6.3 arthroscopic acromioplasties per candidate were reported. Over these ten years, the mean number of arthroscopic acromioplasties reported increased by 142.3%, compared with only a 13.0% increase in the mean number of all orthopaedic surgery procedures. In 2008, as compared with 1999, candidates were 2.2 times more likely to report an arthroscopic acromioplasty compared with all other orthopaedic procedures (p < 0.0001). There has been a substantial increase in the overall volume and the population-based incidence of acromioplasties in recent years on both the state and national levels in the United States. The reasons for this increase have yet to be determined and are likely multifactorial, with patient-based, surgeon-based, and systems-based factors all playing a role.

Ambulatory orthopaedic surgery patients’ knowledge expectations and perceptions of received knowledge

This paper is a report of a study to compare orthopaedic ambulatory surgery patients' knowledge expectations before admission and their perceptions of received knowledge 2 weeks after discharge. Advances in technology and population ageing are driving up the number of ambulatory orthopaedic surgical procedures. Shorter hospital stays present a major challenge for patient education. A descriptive comparative cross-sectional study (pre- and post-test) design was adopted. The data were collected from 120 consecutive patients in 2004, using the Hospital Patient's Knowledge Expectations Scale and Hospital Patient's Received Knowledge Scale. All patients participated in a preoperative education session given by a nurse. Patients expected more knowledge than they actually perceived that they received on all dimensions except the bio-physiological. They perceived that they received least knowledge about experiential, ethical, social and financial dimensions of knowledge. Knowledge expectations correlated with age and professional education. Perceptions of received knowledge correlated with earlier ambulatory surgery, and both expected knowledge and perceptions of received knowledge were related to the level of basic education. Patients' knowledge expectations are greater than the knowledge they perceived that they receive, and they cannot become empowered if they lack important knowledge. Further research is needed to learn about meeting patients' knowledge expectations.