A Randomized Trial of Three Routes of Tranexamic Acid Administration in Total Knee Arthroplasty.

Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion rates across a variety of routes of administration and doses in the setting of total knee arthroplasty (TKA). Oral TXA is less studied but has decreased cost and increased ease of administration. This prospective, randomized study compared the efficacy and cost of three routes of TXA administration in the setting of primary TKA. Primary outcomes were 24-hour hemoglobin loss, calculated blood loss, and blood transfusion rate. One-way analysis of variance, Pearson's chi-square test, and Fisher's exact test were used for statistical analysis. One hundred eleven patients were enrolled. The mean 24-hour hemoglobin loss for the intravenous (IV), oral, and topical TXA groups was 2.50±0.95 g/dL, 2.64±0.94 g/dL, and 2.52±0.90 g/dL, respectively, with no clinical or statistically significant differences among the groups (P=.79). Calculated blood loss was not significantly different (P=.61) among the IV TXA (1067±371 mL), oral TXA (1127±455 mL), and topical TXA (1027±454 mL) groups. No patients in any treatment group required a blood transfusion. IV, oral, and topical routes of TXA administration offer similar clinical benefits for perioperative bleeding and blood transfusion rate in TKA. Oral TXA provides a cost-benefit relative to the other routes of administration ($14 vs $114 per patient), making it a more cost-effective choice. Oral TXA has additional logistical challenges compared with other routes of administration due to increased absorption time, which may impact its use in clinical practice. [Orthopedics. 2023;46(5):285-290.].

Spinal Anesthesia Using Ropivacaine Leads to Earlier Ambulation After Total Hip Arthroplasty.

Spinal anesthesia has grown in popularity for total hip arthroplasty (THA) due to its documented low complications. However, the use of a local anesthetic agent dictates the recovery of neuraxial blockade. Bupivacaine has emerged as the most popular choice, but its relatively long-acting effect limits its use with rapid recovery. Although not well studied, ropivacaine may offer a viable alternative with shorter-acting properties. Primary unilateral THA patients who received either ropivacaine or bupivacaine spinal anesthesia were retrospectively reviewed. These groups were compared for common demographics, such as age, sex, and body mass index. The primary outcomes included postoperative ambulation time and distance, post-anesthesia care unit transition time, and selective complications. Five hundred three patients were included. Of these, 227 received ropivacaine and 276 received bupivacaine. The ropivacaine group showed superior ambulation time and distance, quicker post-anesthesia care unit transition, and equivalent complications compared with the bupivacaine group. Ropivacaine shows a clear advantage over bupivacaine for spinal anesthesia during THA when considering rapid recovery. Its use should be strongly considered, especially in the ambulatory setting. [Orthopedics. 2021;44(3):e343-e346.].

Evaluating the Success of Perioperative Self-Guided Meditation in Reducing Sleep Disturbance After Total Knee Arthroplasty.

BACKGROUND: Disruptions in sleep and pain are frequent complaints following total knee arthroplasty (TKA). Perioperative sleep disturbances may lead to decreased pain tolerance as well as other consequences. The purpose of this study is to evaluate the effectiveness of self-guided meditation for improving sleep quality following TKA. METHODS: TKA patients, at a single institution, between August 2019 and March 2020 were exposed to a self-guided meditation video during the perioperative period via an online, digital platform. Patients were given an institutionally designed questionnaire to assess sleep quality in the perioperative period. Knee injury and Osteoarthritis Outcome Score-Joint Replacement form, Veterans RAND 12-item Health Survey, and satisfaction scores were also collected. Results were compared between those who reported utilizing the video and those who did not. RESULTS: A total of 380 patients were evaluated. One hundred eighty-nine patients reported utilizing the video, while 191 did not. No significant differences were found among baseline age, gender, or preoperative outcome variables between groups. Postoperatively, the video group's reported time spent actually sleeping improved an average of 52 minutes more than the nonvideo group (95% confidence interval 49.8-52.8 minutes, P < .001). The video group also showed significantly larger decreases in overall sleep awakenings (P < .001), however not pain-related disturbances (P = .726). No significant differences in patient-reported outcome measures were noted between groups. CONCLUSIONS: Sleep quality is an important component of TKA recovery. These findings provide evidence that nonpharmacologic interventions, such as self-guided meditation, may help improve sleep quality in the perioperative period. Future studies are warranted to further investigate their potential benefits.

Comparison of Dexamethasone 4mg vs 8mg Doses in Total Joint Arthroplasty Patients: A Retrospective Analysis.

Introduction Dexamethasone is commonly administered intraoperatively to control postoperative nausea and vomiting (PONV) and pain. There is limited evidence of the ideal dosage of dexamethasone during surgery. Dexamethasone administration may increase blood glucose levels, posing unique challenges in maintaining acceptable blood glucose levels in patients with diabetes. Objective Compare two doses of dexamethasone (4mg and 8mg) for outcomes in patients undergoing hip and knee arthroplasty. Methods Medical records of 3,194 patients having undergone total hip arthroplasty (THA) and total knee arthroplasty (TKA) between January 1, 2016 and December 31, 2017 who were administered dexamethasone were reviewed. The eligible population included male and female patients aged 18-89, who underwent elective hip and knee replacement surgery and were administered dexamethasone intraoperatively. Demographics, clinical variables, and preoperative diabetic status were recorded. Primary outcomes included: blood glucose levels, incidence of PONV, post-anesthesia care unit (PACU) time, and length of stay (LOS). Postoperative complications such as periprosthetic joint injection and urinary tract infections (UTI) were also examined within 90 days of surgery. The 30-day readmissions rate was also collected for analysis. Results There was no PONV in the entire patient population. There were no significant differences between 4mg and 8mg dexamethasone in patients with or without diabetes, for preop to postop blood glucose difference, surgical timing, and post-operative complications. Conclusion Dexamethasone in both 4mg and 8mg dose was effective in PONV prophylaxis. The effects of 4mg and 8mg dexamethasone were the same in individuals with and without diabetes and the increases in blood glucose were not significantly different. Dexamethasone should not be withheld, as its benefits seem to outweigh the risks even in patients with diabetes.

Mobility Technicians: A Viable Solution to Early Ambulation of Total Joint Replacement Patients.

BACKGROUND: Early ambulation of patients with total joint replacement (TJR) has been shown to improve outcomes while reducing length of stay and postoperative complications. Limited physical therapy (PT) resources and late-in-the-day cases may challenge day-of-surgery (POD0) ambulation. At our institution, a Mobility Technician (MT) program, composed of specially trained nurse's aides, was developed to address this issue. PURPOSE: The purpose of this study was to compare the effectiveness of the MT model with a traditional PT model in the early ambulation of patients with TJR. METHODS: Patients undergoing unilateral primary TJR at a single institution between June 1, 2014, and October 31, 2018, were included. Ambulation measures were retrospectively assessed between pre- and post-MT program groups. RESULTS: This study included 11,777 patients with TJR. Following the MT program, number of POD0 ambulations, POD0 ambulation distance, and total distance ambulated all increased while time-to-first ambulation decreased. CONCLUSION: Preliminary analyses indicate that the MT program has been successful in the early ambulation of patients with TJR.

Considering healthcare value and associated risk factors with postoperative urinary retention after elective laminectomy.

BACKGROUND: Mitigating common complications such as postoperative urinary retention (POUR) following elective spine surgery is prudent. Identifying patients at risk for POUR and recognizing associated factors, to avoid a more complicated postoperative episode should be a priority and easily achievable. Understanding the financial burden of complications, such as POUR, is also important for value-based healthcare, not only for providers, but for employers and payors as well. PURPOSE: The purpose of this study is to examine patient and surgical factors that may lead to increased risk for POUR and its associated cost following elective lumbar laminectomies. STUDY DESIGN/SETTING: This is a retrospective study of the incidence of postoperative urinary retention after elective one- and two-level primary lumbar laminectomies. PATIENT SAMPLE: We followed patients undergoing one- and two-level primary elective lumbar laminectomies performed between April 2014 and December 2016. OUTCOME MEASURES: Patient factors included age, gender, body-mass index, and comorbidities. Surgical factors included surgical time, intraoperative fluid volume requirements, anesthesia type, and surgical levels involved. Other outcome variables included length of stay, discharge disposition, 30-day all-cause readmissions and emergency department visits, 90-day complications, and variable direct costs. METHODS: The incidence of POUR was evaluated and compared with patient and surgical factors and cost-specific variables to identify correlations and potential risk for POUR after one- and two-level primary lumbar laminectomies. RESULTS: Analysis included 333 patients - 203 one-level laminectomies and 130 two-level laminectomies. The overall incidence of POUR was 17.4%. Age, male gender, and history of urinary retention were significantly associated with POUR. There was a significantly increased risk of POUR with increased surgical time, but not with anesthesia type. There were also no significant differences in body-mass index, other study comorbidities, intraoperative fluid requirements, readmission, emergency department visit, and complication rates between groups. On average, patients with POUR had a significantly longer length of stay than patients without POUR. In addition, more POUR patients were discharged to acute rehabilitation facilities and had higher average variable direct cost compared tonon-POUR patients. CONCLUSIONS: POUR is a significant risk after elective laminectomy. This study supports several widely accepted beliefs regarding POUR risk, while challenging others. It also highlights the burden of POUR development after surgery. At our institution, we developed a protocol supported by these findings.

Hospital Use of Observation Stays: Cross-sectional Study of the Impact on Readmission Rates.

BACKGROUND: The Centers for Medicare and Medicaid Services publicly reports hospital risk-standardized readmission rates (RSRRs) as a measure of quality and performance; mischaracterizations may occur because observation stays are not captured by current measures. OBJECTIVES: To describe variation in hospital use of observation stays, the relationship between hospitals observation stay use and RSRRs. MATERIALS AND METHODS: Cross-sectional analysis of Medicare fee-for-service beneficiaries discharged after acute myocardial infarction (AMI), heart failure, or pneumonia between July 2011 and June 2012. We calculated 3 hospital-specific 30-day outcomes: (1) observation rate, the proportion of all discharges followed by an observation stay without a readmission; (2) observation proportion, the proportion of observation stays among all patients with an observation stay or readmission; and (3) RSRR. RESULTS: For all 3 conditions, hospitals' observation rates were <2.5% and observation proportions were <12%, although there was variation across hospitals, including 28% of hospital with no observation stay use for AMI, 31% for heart failure, and 43% for pneumonia. There were statistically significant, but minimal, correlations between hospital observation rates and RSRRs: AMI (r=-0.02), heart failure (r=-0.11), and pneumonia (r=-0.02) (P<0.001). There were modest inverse correlations between hospital observation proportion and RSRR: AMI (r=-0.34), heart failure (r=-0.26), and pneumonia (r=-0.21) (P<0.001). If observation stays were included in readmission measures, <4% of top performing hospitals would be recategorized as having average performance. CONCLUSIONS: Hospitals' observation stay use in the postdischarge period is low, but varies widely. Despite modest correlation between the observation proportion and RSRR, counting observation stays in readmission measures would minimally impact public reporting of performance.