Although most patients with limb-length discrepancy following total hip arthroplasty have manageable symptoms, others may be disabled as a result of pain or functional impairment. In these patients, ...reoperation may be indicated to equalize the limb lengths. There is a paucity of published data regarding the outcome of surgical intervention to treat this problem. The purpose of the present study was to evaluate the results of revision hip surgery for the treatment of symptomatic limb-length discrepancy.
We retrospectively reviewed the clinical and radiographic records of patients who had undergone revision hip surgery at our institution for the treatment of a symptomatic limb-length discrepancy following a previous total hip arthroplasty. We identified twenty-one patients (twenty-one hips) who had an average age of sixty-six years at the time of revision hip arthroplasty. The average duration of follow-up was 2.8 years, and no patient was lost to follow-up. The indications for revision hip arthroplasty were severe hip and/or back pain for eleven patients, instability of the hip for eight, hip pain and ipsilateral limb paresthesia for one, and hip pain and ipsilateral foot drop for one.
Revision arthroplasty was performed at a mean of eight months (range, six days to six years) after primary total hip replacement. The mean limb-length discrepancy at the time of the revision was 4 cm (range, 2 to 7 cm). Following revision arthroplasty, which involved revision of a malpositioned acetabular and/or femoral component, equalization of the limb lengths was achieved in fifteen patients. In the remaining six patients, the mean discrepancy had decreased to 1 cm. The mean Harris hip score improved significantly, from 56.5 points before the revision to 83.2 points at the time of the latest follow-up (p < 0.005). All but two patients were satisfied with the outcome of the revision surgery.
Limb-length discrepancy following hip arthroplasty can be associated with pain, paresthesia, and hip instability. In these patients, careful evaluation of the position and orientation of the components may reveal the cause of the discrepancy. Revision arthroplasty may be indicated when a surgically correctable cause of limb-length discrepancy can be identified.
When the phase I postanesthesia care unit (PACU) is at capacity, completed cases need to be held in the operating room (OR), causing a "PACU delay." Statistical methods based on historical data can ...optimize PACU staffing to achieve the least possible labor cost at a given service level. A decision support process to alert PACU charge nurses that the PACU is at or near maximum census might be effective in lessening the incidence of delays and reducing over-utilized OR time, but only if alerts are timely (i.e., neither too late nor too early to act upon) and the PACU slot can be cleared quickly. We evaluated the maximum potential benefit of such a system, using assumptions deliberately biased toward showing utility.
We extracted 3 years of electronic PACU data from a tertiary care medical center. At this hospital, PACU admissions were limited by neither inadequate PACU staffing nor insufficient PACU beds. We developed a model decision support system that simulated alerts to the PACU charge nurse. PACU census levels were reconstructed from the data at a 1-minute level of resolution and used to evaluate if subsequent delays would have been prevented by such alerts. The model assumed there was always a patient ready for discharge and an available hospital bed. The time from each alert until the maximum census was exceeded ("alert lead time") was determined. Alerts were judged to have utility if the alert lead time fell between various intervals from 15 or 30 minutes to 60, 75, or 90 minutes after triggering. In addition, utility for reducing over-utilized OR time was assessed using the model by determining if 2 patients arrived from 5 to 15 minutes of each other when the PACU census was at 1 patient less than the maximum census.
At most, 23% of alerts arrived 30 to 60 minutes prior to the admission that resulted in the PACU exceeding the specified maximum capacity. When the notification window was extended to 15 to 90 minutes, the maximum utility was <50%. At most, 45% of alerts potentially would have resulted in reassigning the last available PACU slot to 1 OR versus another within 15 minutes of the original assignment.
Despite multiple biases that favored effectiveness, the maximum potential benefit of a decision support system to mitigate PACU delays on the day on the surgery was below the 70% minimum threshold for utility of automated decision support messages, previously established via meta-analysis. Neither reduction in PACU delays nor reassigning promised PACU slots based on reducing over-utilized OR time were realized sufficiently to warrant further development of the system. Based on these results, the only evidence-based method of reducing PACU delays is to adjust PACU staffing and staff scheduling using computational algorithms to match the historical workload (e.g., as developed in 2001).
The risk of perioperative stroke following cardiac and carotid artery surgery is well documented. There is an apparent lack of recognition and appreciation of this complication after total joint ...arthroplasty. The present study was designed to determine the prevalence of, and outcome after, perioperative stroke following total joint arthroplasty. In addition, risk factors for the development of this complication were evaluated in an attempt to identify a strategy that could minimize the prevalence of this complication.
We performed an observational study of 18,745 consecutive patients undergoing primary or revision total hip or total knee arthroplasty from 2000 to 2007 at our institution. The institutional perioperative stroke rate was 0.2% (thirty-six of 18,745). The thirty-six patients who had a stroke included seventeen men and nineteen women with a mean age of 68.2 years (range, forty-five to eighty-seven years). The average duration of follow-up for all patients and controls in the present study was sixty-two months (range, zero to 124.9 months). In a predictive model, different patient-related and surgery-related factors that could predispose patients to this complication and/or affect outcome were evaluated.
The first-year mortality among stroke patients was 25% (nine of thirty-six), and four of these nine patients died in the hospital following total joint arthroplasty. Of three patients who received emergency intra-arterial thrombolysis, two had complete neurologic recovery and one died in the hospital. The final regression model showed that a history of noncoronary heart disease, urgent (versus elective) surgery, general (versus regional) anesthesia, and an intraoperative arrhythmia or other alterations in the heart rate during surgery are significant predictors of perioperative stroke.
Perioperative stroke is a rare but potentially devastating complication of total joint arthroplasty, with a high rate of morbidity and mortality. Vigilant attention to prevent, detect, and treat this complication in a timely manner may alter the course of the disease.
Abstract The purpose of this study was to determine if adherence to the surgical care improvement project (SCIP) measures could further reduce rate of surgical site infection (SSI) and venous ...thromboembolism (VTE) in total joint arthroplasty (TJA) patients. We retrospectively identified all patients who underwent primary or revision TJA at our institution between July 2000 and June 2009. After implementation of SCIP measures, rate of superficial SSI increased (0.42% versus 0.60%, P = 0.05) while rate of deep SSI decreased from 0.92% to 0.82% ( P = 0.46). The rate of DVT was 0.92% before and 0.83% after implementation of SCIP ( P = 0.51); however, rate of PE increased from 0.87% to 1.30% ( P = 0.002). Our findings indicated that SCIP has not been successful in reducing complications in TJA patients.
Vascular Injuries After Total Joint Arthroplasty Parvizi, Javad, MD, FRCS; Pulido, Luis, MD; Slenker, Nicholas, MD ...
The Journal of arthroplasty,
12/2008, Letnik:
23, Številka:
8
Journal Article
Recenzirano
Abstract Vascular injuries, although highly feared, can occur after total joint arthroplasty, often resulting in legal suits. This study evaluates the circumstances related to vascular injuries after ...joint arthroplasty. Using prospectively collected data on 13 517 patients undergoing total joint arthroplasty at our institution, 16 (0.1%) vascular injuries were identified. Eleven injuries occurred after total knee arthroplasty (TKA) and 5 after total hip arthroplasty (THA). Indirect injury was the most common mechanism in TKA. In contrast, direct injury was most prevalent in THA. One patient died of complications related to vascular injury. Of 16 patients, 8 (50%) had launched a legal suit against the operating surgeon. There appears to be no further specific measure that can be taken to absolutely avoid this complication. Patient awareness regarding this real problem may play a role in defraying the high likelihood of legal suits associated with this complication.
Although it has been shown that the risk of anterior knee pain is greater in patients with nonresurfaced patellae, it is not exactly clear whether the pain would resolve with secondary resurfacing of ...the patella. Thirty-nine patients (41 knees) underwent secondary patellar resurfacing between January 2001 and January 2007. The mean age was 66 years. The mean body mass index was 29.2 kg/m(2). The average time from primary total knee arthroplasty to resurfacing procedure was 29 months. The mean follow-up was 54 months. Anterior knee pain was the indication for secondary resurfacing in all patients. Although the clinical and functional knee scores improved significantly for whole cohort, 8 patients (8 knees) were dissatisfied with the outcome of surgery. This study highlights that secondary resurfacing is not an always rewarding procedure and patients need to be consulted appropriately with regard to the outcome.
Abstract It has been proposed that prevention of deep venous thrombosis (DVT) will lead to a reduction in pulmonary embolism (PE). This retrospective comparative study examines the association ...between symptomatic proximal DVT (occurring at or proximal to the popliteal fossa) and PE in total joint arthroplasty (TJA) patients. We evaluated 1031 patients with DVT symptoms and 428 with PE symptoms. A total of 227 patients were evaluated for both. No statistically significant association found between developing PE and DVT within 90 days after TJA ( P = 0.94). Our findings raise into question the mechanical propagation theory. Formation of DVT and PE may be independent events in patients undergoing TJA. Evaluating the efficacy of thromboprophylaxis using DVT as end point may not reflect its efficacy for prevention of PE.
This study reports the outcome of total hip arthroplasty with use of an uncemented, tapered stem with a 5- to 9-year follow-up. The first 200 consecutive patients (214 hips) undergoing total hip ...arthroplasty with the Accolade TMZF stem (Stryker Orthopaedics, Mahwah, NJ) were enrolled prospectively. Follow-up for these patients averaged 7.6 years and encompassed review of clinical records as well as review of serial anteroposterior and lateral radiographs. There were 5 revision surgeries for aseptic loosening, 2 cases of infection, instability, and polyethylene wear. Our failure rate, defined as hips needing revision, was 2.6%, and the failure rate due to aseptic loosening of the femoral component was 0.6%. These results demonstrate the high success rate of this implant providing support for its continued use.
Surgical cancellation rates typically are reported as the number of cancelled cases divided by the number of scheduled cases. However, the total number of cancelled minutes also has financial impact ...on surgeons' productivity. Cancellation rates can instead be calculated based on the number of minutes of cancelled cases. Hospitals typically benchmark cancellation rates, since not all cancellations are preventable (e.g., those due to new onset of patient symptoms requiring further workup and treatment before surgery can safely proceed). If the mean estimated duration of cancelled cases were the same as that of scheduled cases, rates would be equivalent whether calculated using the number of cancellations or the minutes of cancellations. It is unknown whether there is a difference between these 2 methods.
Data for elective, regular workday cases scheduled were obtained from 2 academic hospitals and binned into 8 sequential 13-week periods. Cancellation rates after 7:00 am or after 7:00 pm on the working day before surgery were calculated by service as (1) the numeric cancellation rate = number cancelled divided by the number scheduled and (2) the duration cancellation rate = minutes cancelled divided by the minutes scheduled. Mean differences (biases) and 95% prediction limits between the numeric and duration cancellation rates were determined.
The hospitals' numeric cancellation rates after 7:00 am (11.6% and 10.7%) were similar to 12.2% from an academic hospital survey. Bias by individual service ranged from -1.16% ± 1.34% to 1.93% ± 3.01% at one hospital and -1.08% ± 2.76% to 3.05% ± 1.89% at the other. Mean differences between matching services at the hospitals were -0.7% ± 0.6% to 3.3% ± 0.3%. There was considerable variability among services for numeric cancellation rates and the prediction limits of the cancellation rate, calculated using the number of minutes cancelled.
Calculating cancellation rates using case counts can inaccurately represent their impact on surgeon's productivity compared with using minutes of cancelled cases. Comparing numeric cancellation rates between hospitals or services without checking for bias may lead to inappropriate conclusions. We recommend that hospitals evaluate their data for potential bias to determine whether cancellation rates need to be calculated using scheduled minutes of cases rather than numbers of cancellations.
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