Gens P. Goodman

Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients.

BACKGROUND The purpose of this investigation was to determine the incidence rates of, and identify risk factors for, thirty-day postoperative mortality and complications among more than 15,000 patients who underwent a primary unilateral total knee arthroplasty as documented in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). METHODS The NSQIP database was queried to identify patients who had undergone primary unilateral total knee arthroplasty between 2006 and 2010. Patient demographics, medical history, and surgical characteristics were recorded, as were thirty-day postoperative complications, mortality, and length of hospital stay. Complications were divided into categories, which included major systemic complications (complications requiring complex medical intervention) and major local complications (including deep wound infection and peripheral nerve injury). Univariate testing and multivariate logistic regression analysis were used to identify significant independent predictors of the outcome measures. RESULTS A total of 15,321 individuals underwent primary unilateral total knee arthroplasty. The mean age (and standard deviation) of the patients was 67.3 ± 10.2 years. Obesity (a body mass index [BMI] of ≥30 kg/m²) was documented in 61.2% of cases, 18.2% of patients had diabetes, and 50% were graded as Class 3 or higher on the basis of the American Society of Anesthesiologists (ASA) classification system. The thirty-day mortality rate was 0.18%, and 5.6% of the patients experienced complications. Patient age (odds ratio [OR] = 1.12; 95% confidence interval [CI] = 1.06 to 1.17) and diabetes (OR = 2.99; 95% CI = 1.35 to 6.62) were independent predictors of mortality. A BMI of ≥40 kg/m² was an independent predictor of postoperative complications (OR = 1.47; 95% CI = 1.09 to 1.98). Patient age of eighty years or older, an ASA classification of ≥3, and an operative time of >135 minutes influenced the development of any postoperative complication as well as major and minor systemic complications. Cardiac disease (OR = 4.32; 95% CI = 1.01 to 18.45) and a BMI of ≥40 kg/m² (OR = 2.01; 95% CI = 1.02 to 3.97) were associated with minor local complications. CONCLUSIONS Patient age and diabetes increased the risk of mortality after primary total unilateral knee arthroplasty. Predictive factors impacting the development of postoperative complications included an ASA classification of ≥3, increased operative time, increased age, and greater body mass.

Disease and nonbattle injuries sustained by a U.S. Army Brigade Combat Team during Operation Iraqi Freedom.

BACKGROUND A longitudinal cohort analysis of disease nonbattle injuries (DNBI) sustained by a large combat-deployed maneuver unit has not been performed. METHODS A descriptive analysis was undertaken to evaluate for DNBI casualty care statistics incurred by a U.S. Army Brigade Combat Team (BCT) during a counterinsurgency campaign of Operation Iraqi Freedom. RESULTS Of the 4,122 soldiers deployed, there were 1,324 DNBI with 5 (0.38%) deaths, 208 (15.7%) medical evacuations (MEDEVAC), and 1,111 (83.9%) returned to duty. The DNBI casualty rate for the BCT was 257.0/1,000 soldier combat-years. Females, compared with males, had a significantly increased incidence rate ratio for becoming a DNBI casualty 1.67 (95% CI 1.37, 2.04). Of 47 female soldiers receiving MEDEVAC 35 (74%) were for pregnancy-related issues. Musculoskeletal injuries (50.4%) and psychiatric disorders (23.3%) were the most common body systems involved with DNBI casualties. Among the BCT cohort the psychiatric DNBI casualty rate and suicide rate were 59.8 and 0.58 per 1,000 soldier combat-years. The BCT cohort incidence rates for common musculoskeletal injuries per 1,000 combat-years were as follows: ankle sprain 15.3, anterior cruciate ligament rupture 3.3 and shoulder dislocation 1.2. CONCLUSIONS Musculoskeletal injuries and psychiatric disorders accounted for 74% of the total DNBI casualties, and 43% of the DNBI casualties requiring subsequent MEDEVAC. The BCT cohort had a suicide rate nearly four times greater than previously reported, and selected musculoskeletal injury incidence rates were fivefold greater than the general population.

Morbidity and Mortality in the Thirty-Day Period Following Total Hip Arthroplasty: Risk Factors and Incidence

The study sought to ascertain the incidence rates and risk factors for 30-day post-operative complications after primary total hip arthroplasty (THA). Complications were categorized as systemic or local and subcategorized as major or minor. There were 17,640 individuals who received primary THA identified from the 2006-2011 ACS NSQIP. The mortality rate was 0.35% and complications occurred in 4.9%. Age groups ≥ 80 years (P <0.001) and 70-79 years old (P = 0.003), and renal insufficiency (P = 0.02) best predicted mortality. Age ≥80 years (P <0.001) and cardiac disease (P = 0.01) were the strongest predictors of developing any postoperative complication. Morbid obesity (P <0.001) and operative time > 141 minutes (P <0.001) were strongly associated with the development of major local complications.

Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence.

BACKGROUND Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty. METHODS The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed. RESULTS For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined). CONCLUSIONS An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and co-management in the perioperative period for individuals with these risk factors.

The Influence of Musculoskeletal Conditions, Behavioral Health Diagnoses, and Demographic Factors on Injury-Related Outcome in a High-Demand Population

BACKGROUND The extent to which musculoskeletal injuries and sociodemographic factors impact long-term outcome remains unknown. The purpose of this study was to provide a prognostic analysis of the influence of musculoskeletal conditions, behavioral health diagnoses, and patient-based characteristics on outcomes among a longitudinal cohort. METHODS This is a longitudinal observational study of the population of an Army brigade deployed to Iraq from 2006 to 2007. The 4087 soldiers who survived the deployment were followed for forty-eight months and were observed for the development of chronic musculoskeletal conditions, behavioral health disorders, and inability to remain in active service as indicated by the findings of the Physical Evaluation Board. The influence of demographic factors, behavioral health conditions, and deployment-related musculoskeletal injuries on the capacity to remain in the military was assessed using Poisson multivariate analysis and receiver operating characteristic curves. RESULTS The mean age of the cohort was twenty-seven years (range, eighteen to fifty-two years). One hundred and sixty-three soldiers sustained combat-related musculoskeletal trauma, and 587 soldiers had musculoskeletal injuries not related to battle. Three hundred and seventy-four soldiers (9%) were found to be unfit by the Physical Evaluation Board, with 236 soldiers (63%) referred for at least one musculoskeletal condition. Of these 236 soldiers, 116 (49%) also had a behavioral health diagnosis. Multivariate regression analysis revealed that junior enlisted rank (incidence rate ratio, 9.7 [95% confidence interval, 3.1 to 30.3]), senior enlisted rank (incidence rate ratio, 5.6 [95% confidence interval, 1.8 to 17.7]), behavioral health diagnosis (incidence rate ratio, 7.4 [95% confidence interval, 5.6 to 9.6]), age of eighteen to twenty-three years (incidence rate ratio, 1.6 [95% confidence interval, 1.2 to 2.3]), and male sex (incidence rate ratio, 2.5 [95% confidence interval, 1.2 to 5.0]) were significant predictors of referral to the Physical Evaluation Board for a musculoskeletal condition. A prognostic model developed using receiver operating characteristic curves and the risk factors of musculoskeletal injury, presence of a psychiatric condition, and lower rank explained 78% (95% confidence interval, 77% to 80%) of the risk of being found unfit by the Physical Evaluation Board. CONCLUSIONS Musculoskeletal conditions, psychological diagnoses, and lower rank (socioeconomic status) were identified as potent predictors of inferior outcome in this study. Targeting at-risk patients within populations may improve results. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Non-emergent orthopaedic injuries sustained by soldiers in operation Iraqi freedom

BACKGROUND The majority of soldiers deployed to the theater of combat operations return safely after completion of the deployment. Many of these soldiers sustain non-emergent musculoskeletal injuries that initially are treated nonoperatively and ultimately require surgery following their combat tour. METHODS A prospective evaluation of the orthopaedic surgery consultations and surgical procedures required by soldiers returning from a full combat deployment was performed. Demographic information (including age and sex) as well as information on the mechanism of injury, the reason for orthopaedic consultation, and the procedures performed was collected for each soldier. The overall incidence of non-emergent orthopaedic injuries was calculated, and multivariate Poisson regression analysis was utilized to determine the effect of age and sex on the type of orthopaedic injury sustained. RESULTS There were 3787 soldiers who returned from combat operations at the end of a fifteen-month deployment without having been medically evacuated. There were 731 orthopaedic surgical consultations for the evaluation of a non-emergent musculoskeletal complaint, and 140 orthopaedic operations were performed as a result. An age of thirty years or more was an important risk factor for requiring an orthopaedic consultation (p < 0.0001). The most common surgical procedures were performed for shoulder stabilization, for superior labrum anterior to posterior lesion repair, for the treatment of internal derangement of the knee, and for the treatment of foot deformity. CONCLUSIONS Nineteen percent of all soldiers who completed a combat deployment required an orthopaedic surgical consultation on return, and 4% of soldiers required orthopaedic surgery. More than half of the surgical procedures involved the knee or shoulder. This represents a large burden of care for returning soldiers on orthopaedic surgical services and has important implications for future resource utilization.

The Shift to Same-day Outpatient Joint Arthroplasty: A Systematic Review

BACKGROUND Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty. METHODS We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation. RESULTS Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again. CONCLUSION For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Intraoperative Fluoroscopy with a Direct Anterior Approach Reduces Variation in Acetabular cup Abduction Angle

Introduction The purpose of this study was to compare acetabular cup position for 2 cohorts of total hip arthroplasty (THA) patients who had a direct anterior approach. Methods 100 THA cases were performed with an anterior approach using intraoperative fluoroscopy (IF) to aid in cup positioning. Another group of 100 cases underwent THA with an anterior approach without the use of any fluoroscopy. Postoperative abduction and anteversion angles were measured using Martells hip analysis software. Results Mean abduction angle was 43.2° (standard deviation (SD) = 4.5°) for the IF group versus 37.5°(SD = 7.4°) for cases without IF (p<0.001). 18% more cases with IF fell within the Lewinnek safe zone (p<0.001); however, a similar number of cases had over 50° of abduction. The mean anteversion angles of the two groups were also significantly different (IF 21.8° vs. 24.9°) (p<0.01). Conclusions There was significantly less variation in cup position among the cases using IF with regards to abduction.