The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols

doi:10.1016/j.arth.2019.11.037

The Journal of Arthroplasty

Volume 35, Issue 4, April 2020, Pages 950-954

https://doi.org/10.1016/j.arth.2019.11.037 Get rights and content

Abstract

Background

Compared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol.

Methods

This is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA.

Results

Patients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034).

Conclusion

NA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities.

Level Of Evidence

Level III Retrospective Cohort Study.

Section snippets

Materials and Methods

Institutional review board approval was obtained. A retrospective chart review was performed for a consecutive series of primary unilateral TJA performed between July 2015 and June 2018. Surgeries were performed by 1 of 13 board-certified orthopedic surgeons at a single institution. All surgeries were conducted post-implementation of a standardized institutional rapid recovery protocol which remained constant over the study period. Data were collected via an administrative database for patient

Results

In total, 2896 patients (49.0%) received GA and 3018 (51.0%) received NA. Over the study time period, the proportion of patients receiving NA increased from 43.3% in 2015 to 56.2% in 2018. When examining TKA and THA patients separately (Table 1), patients receiving NA had a lower BMI (THA: GA 30.43 vs NA 29.13 kg/m², P < .001; TKA: GA 33.14 vs NA 31.44, kg/m², P < .001) and a lower percentage of ASA 3 or 4 (THA: GA 47.0% vs NA 30.6%, P < .001; TKA: GA 50.2% vs NA 38.7%, P < .001). TKA patients

Discussion

THA and TKA are typically successful and most patients report improved pain, quality of life, and physical and mental health following recovery from these procedures [[17], [18], [19]]. In part because of this success, the number of these surgeries performed annually continues to increase, necessitating that the healthcare system builds on prior improvements in quality of care and cost containment efforts associated with surgical intervention. Decreasing LOS, increasing home discharge, and

Conclusion

NA appears to contribute to decreased LOS, decreased short-term complications, and decreased transfusions while facilitating home discharge in patients undergoing TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, BMI, and comorbid conditions undergoing TJA. Increased utilization of NA may improve patient outcomes and decrease costs associated with these procedures and should be

References (36)

D.B. Auyong et al.
Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway
J Arthroplasty
(2015)
B.D. Haughom et al.
Does neuraxial anesthesia decrease transfusion rates following total hip arthroplasty?
J Arthroplasty
(2015)
J.M. Richman et al.
Does neuraxial anesthesia reduce intraoperative blood loss? A meta-analysis
J Clin Anesth
(2006)
N.S. Key et al.
Chapter 34 - Inherited disorders of coagulation
C.R.K. Grant et al.
Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia
Contin Educ Anaesth Crit Care Pain
(2008)
B.A. Tarakji et al.
Improvement in depression and physical health following total joint arthroplasty
J Arthroplasty
(2018)
J.K. Lange et al.
Satisfaction rates and quality of life changes following total knee arthroplasty in age-differentiated cohorts
J Arthroplasty
(2018)
A.H. Stone et al.
Reducing length of stay does not increase emergency room visits or readmissions in patients undergoing primary hip and knee arthroplasties
J Arthroplasty
(2018)
P.M. Courtney et al.
Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty
J Arthroplasty
(2015)
M.J. Grosso et al.
Decreasing length of hospital stay and postoperative complications after primary total hip arthroplasty: a decade analysis from 2006 to 2016
J Arthroplasty
(2019)

P.M. Courtney et al.

Should Medicare remove total knee arthroplasty from its inpatient only list? A total knee arthroplasty is not a partial knee arthroplasty

J Arthroplasty

(2018)

C.J. Gronbeck et al.

Predicting inpatient status after total hip arthroplasty in Medicare-aged patients

J Arthroplasty

(2019)

J. Guay

The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis

J Clin Anesth

(2006)

Y.A. Fillingham et al.

Tranexamic acid use in total joint arthroplasty: The clinical practice guidelines endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society

J Arthroplasty

(2018)

J.B. Stambough et al.

Rapid recovery after total joint arthroplasty using general anesthesia

J Arthroplasty

(2019)

U.S. Sibia et al.

The cost of unnecessary hospital days for Medicare joint arthroplasty patients discharging to skilled nursing facilities

J Arthroplasty

(2017)

C.I. Nichols et al.

Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty

J Arthroplasty

(2016)

A.J. Clair et al.

Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative

J Arthroplasty

(2016)

Cited by (24)

Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review
2024, Journal of Cardiothoracic and Vascular Anesthesia
Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication—noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)—with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors’ data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors’ results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.
Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study
2024, Journal of Arthroplasty
Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC).
We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine).
All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445).
Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively.
Level 3, Retrospective Cohort Comparison.
Spinal Versus General Anesthesia in Contemporary Revision Total Knee Arthroplasties
2023, Journal of Arthroplasty
Interest in spinal anesthesia utilization in revision total knee arthroplasties (TKAs) is rising. This study investigated the pain control, length of stay (LOS), and complications associated with spinal versus general anesthesia in a single institution series of revision TKAs.
We identified 3,711 revision TKAs (3,495 patients) from 2001 to 2016 using our institutional total joint registry. There were 66% who had general anesthesia and 34% who had spinal anesthesia. Mean age, sex, and BMI were similar between groups at 67 years, 53% women, and 32, respectively. Data were analyzed using inverse probability of treatment weighted models based on propensity scores that accounted for patient and operative factors. Mean follow-up was 6 years (range, 2 to 17).
Patients treated with spinal anesthesia required fewer postoperative oral morphine equivalents (OMEs) (P < .0001) and had lower numeric pain rating scale scores (P < .001). Spinal anesthesia was associated with shorter LOS (4.0 versus 4.6 days; P < .0001), less cases of altered mental status (AMS; Odds Ratio (OR) 2.0, P = .004), less intensive care unit (ICU) admissions (OR 1.6, P = .02), fewer re-revisions (OR 1.7, P < .001), and less reoperations (OR 1.4, P < .001). There was no difference in the incidence of VTE (P = .82), 30-day readmissions (P = .06), or 90-day readmissions (P = .18) between anesthetic techniques.
We found that spinal anesthesia for revision TKAs was associated with significantly lower pain scores, reduced OME requirements, and decreased LOS. Furthermore, spinal anesthesia was associated with fewer cases of AMS, ICU admissions, and re-revisions even after accounting for numerous patient and operative factors.
Level III, Retrospective Comparative Study.
Spinal Versus General Anesthesia in Total Knee Arthroplasty: Are There Differences in Complication and Readmission Rates?
2023, Journal of Arthroplasty
Citation Excerpt :
The difference in the magnitude of the effect sizes observed between our study and the study by Warren et al. may be related to the longer 90-day follow-up period assessed in the present study. While the current study did not assess postoperative medical and surgical complications, several contemporary studies assessing differences in complication rates between TKA patients receiving spinal and general anesthesia have found favorable results among patients receiving spinal anesthesia [12,21,29,30]. Pugely et al. assessed 14,052 primary TKA patients of which 6,030 (42.9%) underwent spinal anesthesia and 8,022 (57.1%) received general anesthesia [12].
Spinal anesthesia (SP) utilization continues to expand in total knee arthroplasty (TKA). However, little is known regarding differences in complication rates between spinal and general anesthesia used for primary TKA. Therefore, the purpose of this study is to compare the length of stay (LOS), operative time, and readmission and revision rates between patients who received spinal and general anesthesia during TKA.
The American Joint Replacement Registry (AJRR) was used to identify primary elective TKA patients from 2017 to 2020. Patients were divided into 2 cohorts, general (GN) and SP, based on the mode of anesthesia administered during the index surgery. In total, 270,251 TKAs were identified, of which 126,970 (47.0%) received general anesthesia and 143,281 (53.0%) received spinal anesthesia. Length of stay, operative time, 90-day readmission, and 90-day revisions were compared between the 2 groups. Multivariable logistic regression analyses were used to adjust for potential confounders.
After accounting for confounding factors, SP was associated with a lower risk of having a LOS greater than 3 days (odds ratio [OR] 0.470, 95% confidence interval [CI] 0.454-0.487, P < .0001), but a slightly higher likelihood of having a longer operative time (OR 1.075, 95% CI 1.056-1.094, P < .0001). SP was also linked to lower rates of 90-day readmission (OR 0.845, 95% CI 0.790-0.904, P < .0001) and lower risk of 90-day all-cause revision (OR 0.506, 95% CI 0.462-0.555, P < .0001).
SP was associated with a lower 90-day readmission rate and a lower risk of 90-day revision. These findings support the best practice guidelines of The Joint Commission to use spinal anesthesia when possible as part of an enhanced recovery after surgery (ERAS) pathway.
Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score–Matched Cohort Analysis
2023, Journal of Arthroplasty
General anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA.
A large veteran’s database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 56,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics.
Upon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients.
Using a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.
Outcomes and Cost Analysis of a Surgical Care Unit for Outpatient Total Joint Arthroplasties Performed at a Tertiary Academic Center
2022, Arthroplasty Today
Citation Excerpt :
This initiative restructured the hospital reimbursement model for TJAs and placed a greater emphasis on value-based care. Hospital systems and orthopedic institutions responded to this change by implementing clinical care pathways geared toward reducing hospital length of stay (LOS) and overall cost of care [4–9]. These pathways have proved successful while maintaining patients' safety as well as clinical and patient-reported outcomes.
Total joint arthroplasty (TJA) has shifted toward being an outpatient surgery with advances in perioperative protocols and patient selection. Most literature on outpatient arthroplasty focuses on the surgery performed in ambulatory centers. This study sought to compare (1) short-term outcomes and (2) the total procedural cost in patients who underwent TJAs at a tertiary academic center and were discharged from the accelerated surgical care unit (SCU) vs the inpatient floor unit.
This is a retrospective review of 1231 procedures (637 total knee arthroplasties and 594 total hip arthroplasties) performed between January 2020 and May 2021 at 1 tertiary academic center. The minimum required follow-up duration was 90 days. Patients were divided into 2 cohorts based on discharge location (SCU vs inpatient). Patient demographics, medical comorbidities, 90-day hospital returns, and revisions were evaluated with univariate and multivariate analyses. Of the 1231 patients, 1092 had available cost data that were analyzed by a univariate analysis.
Patients discharged from the SCU were younger (P < .01), with lower American Society of Anesthesiologists scores (P = .04). SCU patients trended toward fewer 90-day hospital returns and revisions; however, these results were not significant. The overall encounter cost for TJA was significantly lower in patients discharged from the SCU (P < .01). Cost remained significantly less at 30 and 90 days postoperatively (P < .01).
The present study represents the current activity at many large tertiary American academic medical centers. Results demonstrate that a unit for accelerated discharge after TJAs in a tertiary academic center is safe and cost-effective. With proper implementation, its development will enhance arthroplasty programs at a large tertiary academic center.

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: All work was performed at Anne Arundel Medical Center, Annapolis, MD.

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.11.037.

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Primary ArthroplastyThe Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols

Abstract

Background

Methods

Results

Conclusion

Level Of Evidence

Section snippets

Materials and Methods

Results

Discussion

Conclusion

J Arthroplasty

J Arthroplasty

J Clin Anesth

Contin Educ Anaesth Crit Care Pain

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Clin Anesth

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Primary Arthroplasty
The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols