Tyler Kreitz

The Role of Multimodal Analgesia in Spine Surgery

Optimal postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. Historically, pain management after spine surgery relied heavily on opioid medications. Multimodal regimens were developed to reduce opioid consumption and associated adverse effects. Multimodal approaches used in orthopaedic surgery of the lower extremity, especially joint arthroplasty, have been well described and studies have shown reduced opioid consumption, improved pain and function, and decreased length of stay. A growing body of evidence supports multimodal analgesia in spine surgery. Methods include the use of preemptive analgesia, NSAIDs, the neuromodulatory agents gabapentin and pregabalin, acetaminophen, and extended-action local anesthesia. The development of a standard approach to multimodal analgesia in spine surgery requires extensive assessment of the literature. Because a substantial number of spine surgeries are performed annually, a standardized approach to multimodal analgesia may provide considerable benefits, particularly in the context of the increased emphasis on accountability within the healthcare system.

Short-term Outcomes of Total Knee Arthroplasty Performed at an Orthopedic Specialty Hospital

This study compared perioperative outcomes for total knee arthroplasty (TKA) at an orthopedic specialty hospital and a tertiary referral center. The authors identified all primary TKA procedures performed in 2014 at the 2 facilities. Each patient at the orthopedic specialty hospital was manually matched to a patient at the tertiary referral center according to demographic and clinical variables. Matching was blinded to outcomes. Outcomes were 90-day readmission, mortality rate, reoperation, length of stay, and use of inpatient rehabilitation. Each group had 215 TKA patients. The 2 groups of patients were similar in age (66.8 years, P=.98), body mass index (30.4 kg/m2, P=.99), age-adjusted Charlson Comorbidity Index (3.4, P=1.00), and sex (46.0% male, P=1.00). Mean length of stay was 1.47±0.62 days at the orthopedic specialty hospital vs 1.87±0.75 days (P<.01) at the tertiary referral center. There were 3 readmissions at the orthopedic specialty hospital and 6 readmissions at the tertiary referral center (P=.31). There were 6 reoperations at the orthopedic specialty hospital and 5 at the tertiary referral center (P=.76). In addition, 8 patients at the orthopedic specialty hospital used inpatient rehabilitation vs 15 patients at the tertiary referral center (P=.08). One patient who was treated at the orthopedic specialty hospital required transfer to a tertiary referral center. This study found that perioperative outcomes were similar for matched patients who underwent primary TKA at an orthopedic specialty hospital and a tertiary referral center. Patients treated at the orthopedic specialty hospital spent 0.4 fewer days in the hospital compared with matched patients who were treated at the tertiary referral center. This equals 2 fewer hospital nights for every 5 TKA patients. [Orthopedics. 2018; 41(1):e84-e91.].

Comparison of Short-Term Outcomes After Total Hip Arthroplasty Between an Orthopedic Specialty Hospital and General Hospital

BACKGROUND The purpose of this study is to compare perioperative outcomes for total hip arthroplasty (THA) at an orthopedic specialty hospital (OSH) and a general hospital (GH). METHODS A retrospective study of all primary THAs was performed at an OSH and GH in 2014. A cohort of GH patients was manually matched to the OSH by clinical and demographic variables blinded to outcome. These matched groups were then unblinded and compared by length of stay (LOS), 90-day readmissions, mortality, reoperations, and inpatient rehabilitation utilization. RESULTS The 329 THAs at the OSH were matched with 329 THAs at the GH. Average LOS for THA at the OSH was 1.10 ± 0.51 days compared with 1.27 ± 0.93 (P = .004) at the GH. There were 2 OSH readmissions vs 5 GH readmissions (P = .25). There were 3 OSH reoperations vs 4 GH reoperations (P = .70). There were no mortalities. Three OSH patients used inpatient rehabilitation vs 13 GH patients (P = .011). When GH outlier and rehabilitation patients were excluded, the difference in LOS was not significant (1.08 ± 0.47 vs 1.13 ± 0.55 days; t = 1.331; P = .184). Two OSH patients required transfer to a GH postoperatively (angina and gastrointestinal bleed). CONCLUSION This study found that perioperative outcomes for THA were equally good at the OSH and GH. Rehabilitation utilization was higher at the GH. The LOS at both facilities was lower than the national average of 2.9 days. When rehabilitation patients and outliers were excluded, there was no significant difference in LOS between the two.