A Nationwide Analysis of Preoperative Planning on Operative Times and Postoperative Complications in Total Knee Arthroplasty

Abstract

Compared with nonelective total knee arthroplasties (TKAs), elective procedures have more time for preoperative planning, which allows for potentially improved patient optimization, risk factor modification, and patient education. The purpose of this study was to (1) determine nationwide trends in operative times and (2) evaluate associations between surgery type, elective or nonelective, with respect to (a) operative times, (b) length of stay (LOS), (c) discharge dispositions, (d) 30-day postoperative complications, (e) reoperations, and (f) readmissions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all primary TKAs performed between 2011 and 2016. This yielded 209,178 cases which were stratified into elective and nonelective cases. Elective cases were those in which patients were brought from their normal living environment for scheduled procedures. One-way ANOVA (analysis of variance) was used to evaluate associations between operative times and year of surgery. Multivariate linear and logistic regression models adjusted for surgery year and patient factors (age, sex, BMI [body mass index], and ASA [American Society of Anesthesiologists] score) were used to evaluate associations of surgery type with peri- and postoperative outcomes. A significant inverse correlation between operative times and operative year was observed (p < 0.001). Mean operative times and LOS were significantly shorter in elective cases compared with nonelective cases (93 vs. 112 minutes, p < 0.005; 3 vs. 5 days, p < 0.001). Multivariate analysis showed these associations remained significant even after adjusting for potential confounders (p < 0.001). Compared with the nonelective cohort, patients in the elective cohort were more likely to be discharged home (74 vs. 69%, p < 0.001). Nonelective patients had higher rates of pneumonia (0.7 vs. 0.3%, p = 0.005), organ-space surgical site infections (SSI; 0.4 vs. 0.2%, p = 0.004), transfusions (10.9 vs. 6.5%, p < 0.001), sepsis (0.6 vs. 0.2%, p = 0.001), and septic shock (0.2 vs. 0.1%, p = 0.005) compared with elective patients. These associations remained significant with multivariate logistic regression. This study demonstrated that preoperative planning can help shorten operative times and LOS as well as reduce complication and reoperation rates. Alongside the direct advantages identified in this study, potential greater effects include superior patient outcomes and reduced health care costs.

What Factors Influence Operative Time in Total Knee Arthroplasty? A 10-Year Analysis in a National Sample

“…This was made evident in a recent study by Sodhi et al [31]. The authors demonstrated that operative times were significantly shorter for patients who underwent more extensive preoperative planning compared to those with less planning (93 minutes vs 112 minutes; P < .005) [31]. While further studies are needed to adequately explore this relationship, our findings translate to overall lower costs to healthcare systems due to the decreased likelihood of these adverse outcomes as well as the overall shorter LOS [32,33].…”

“…Additionally, preoperative planning and an increased effort to mitigate these risks postoperatively may have further contributed to these decreased incidences. This was made evident in a recent study by Sodhi et al [31]. The authors demonstrated that operative times were significantly shorter for patients who underwent more extensive preoperative planning compared to those with less planning (93 minutes vs 112 minutes; P < .005) [31].…”

Hospital transfusion service operations during the SARS‐CoV‐2 pandemic: Lessons learned from the AABB hospital survey in preparation for the next infectious disease outbreak

“…Based on this scale, arguably most, if not all, surgical procedures associated with the highest risk of RBC transfusion—and which account for over 50% of surgical patients exposed to RBC transfusion 16 —should not have been postponed. This suggests a significant portion of blood utilization is attributed to elective surgeries, 17 which is somewhat unexpected given that transfusion requirements are higher in non‐ESP compared to ESP 18,19 . Despite the implementation of a maximal surgical blood order schedule to improve the efficiency of blood ordering practices for ESP, 20 crossmatch‐to‐transfusion ratios remain high and/or blood is underutilized 21,22 .…”

Preoperative Care Assessment of Need Scores Are Associated With Postoperative Mortality and Length of Stay in Veterans Undergoing Knee Replacement

“…22 Multiple authors have reported improved outcomes with cost reductions after implementation of programs targeting modifiable risk factors in high-risk surgical candidates. [23][24][25] A preoperative assessment that includes the CAN score may be valuable in identifying patients who would benefit most from prehabilitation programs or other interventions designed to blunt the impact of frailty. It is true that many elements used to calculate the CAN score would not be considered modifiable, especially in the short term.…”