Impact of Operative Time on Adverse Events Following Primary Total Joint Arthroplasty

Bohl, Daniel D.; Ondeck, Nathaniel T.; Darrith, Brian; Hannon, Charles P.; Fillingham, Yale A.; Valle, Craig J. Della

doi:10.1016/j.arth.2018.02.037

Cited by 162 publications

(143 citation statements)

References 33 publications

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“…Previously it has been proved that increased operative time could result in higher complication rate especially infection, venous thromboembolism (VTE) and patient dissatisfaction (24,(26)(27)(28)(29)(30)(31). Each TKA surgery in this study took an average of 60.30 minutes (SD = 44.19) from incision to wound dressing, which is comparable to other reports (27,32).…”

Section: Characteristicssupporting

confidence: 76%

Low Post-Arthroplasty Infection Rate is Possible in Developing Countries: Long-Term Experience of Local Vancomycin Use From A High-Volume Tertiary Knee Center in Iran

Tahmasebi

Vaziri

Vosoughi

et al. 2020

Preprint

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Background: Significant research has been carried out for prevention and also early detection of post-TKA infections. Regarding prevention, utilizing intrawound vancomycin powder in TKA surgery has yielded rather contrasting results in the pertinent literature. Regarding early detection, CDC criteria, although effective in general, are not specifically designed for post-TKA infections. Here, we present a 7-year experience of primary TKA in a high-volume tertiary knee center in Iran, during which intrawound vancomycin powder was used as a routine practice at the end of TKA surgeries. Also, new criteriae are proposed to detect suspected superficial post-TKA infections. Methods: This is a retrospective analysis of primary total knee arthroplasties performed in a tertiary knee center, from March 2011 to December 2018, by a single senior knee surgeon. All patients with follow-up periods of less than one year were excluded from the study. All patient received vancomycin (powder, 1gr) before water-tight closure of the joint capsule. Results: Altogether, 1710 patients were included in the study. Patients were mostly women (male to female ratio: 1 to 4), with a mean age of 64.99 (SD=11.49) years. The overall infection rate was 2.16% (37 of 1710 patients), including 5 periprosthetic deep joint infections and 32 suspected superficial wound infections. Of the 32 suspected superficial infections that were treated with a one-week course of oral antibiotics, all reported disappearance of symptoms, but 2 cases returned with late deep infection. All in all, 7 patients (0.41%) underwent two-stage knee arthroplasty due to deep joint infections. Conclusions: Our experience shows that by utilizing intrawound vancomycin for 7 years as a routine practice along with other measures, we were able to reach relatively low rates of deep post-TKA infections. Howbeit, randomized controlled trials are required to clarify the effect of intrawound vancomycin on post-TKA infection rate.

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Section: Characteristicssupporting

confidence: 76%

Low Post-Arthroplasty Infection Rate is Possible in Developing Countries: Long-Term Experience of Local Vancomycin Use From A High-Volume Tertiary Knee Center in Iran

Tahmasebi

Vaziri

Vosoughi

et al. 2020

Preprint

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“…This may be particularly relevant in the context of postoperative infections as shorter operative times have previously been associated with lower infection rates after TKA. 26,32,33 Furthermore, patient-reported outcomes have also been found to be comparable in a recent review including 66 cementless TKAs and 62 cemented TKAs 17 ; there were similar Oxford knee scores in both cohorts (p ¼ 0.6). Additionally, there was 100% implant survival in both cohorts at a mean follow-up of 1.4 AE 0.5 years.…”

Section: Discussionmentioning

confidence: 71%

“…Operative times, as well as hospital and surgeon volumes were recorded for each case as they have previously shown to influence outcomes in TJA. [26][27][28] Hospital and surgeon volume thresholds were guided by existing literature on volume-outcome relationships in TJA. 29,30 Hospitals performing < 250, 250 to 500, and > 500 TKAs per year were considered low, medium, and high volume, respectively.…”

Section: Study Covariatesmentioning

confidence: 99%

Postoperative Infection in Cementless and Cemented Total Knee Arthroplasty: A Propensity Score Matched Analysis

et al. 2019

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The ongoing debate on fixation in total knee arthroplasty (TKA) has become increasingly relevant with its increased use in a younger patient population and the advent of novel cementless prostheses. Recent literature suggests modern cementless implants are comparable to their cemented counterparts in terms of survivorship and functional outcomes. What has not been well-assessed is whether the two modalities differ with respect to infection rates which was the purpose of this study. Specifically, a propensity score matched study population was used to compare: (1) overall infection; (2) prosthetic joint infection (PJI); and (3) surgical site infection (SSI) rates between cementless and cemented TKAs. Using a large institutional database, 3,180 consecutive primary TKAs were identified. Cementless and cemented TKA patients were propensity score matched by age (p = 0.069), sex (p = 0.395), body mass index (BMI; p = 0.308), and Charlson's comorbidity index (CCI) score (p = 0.616) in a 1:1 ratio. Univariate analysis was performed to compare 2-year overall infection rates. Infections were further analyzed separately as PJIs (deep joint infections requiring surgery) and SSIs (skin/superficial wound infections). Multivariate logistic regression was performed to evaluate infection incidences after adjusting for procedure-related factors (i.e., operative time, hospital volume, and surgeon volume). There were no significant differences between the matched cohorts in terms of overall infection rates (3.8 vs. 2.3%, p = 0.722), as well as when PJI (p = 1.000) and SSI (p = 1.000) rates were analyzed separately. Multivariate analysis revealed no significant differences in overall postoperative infection rates (p = 0.285), PJI rates (p = 0.446), or SSI rates (p = 0.453) even after adjusting for procedure-related factors. There is increasing literature investigating various outcomes demonstrating the comparable efficacies of cementless versus cemented TKAs. To the best of the author's knowledge, this was the first matched case-control study to directly compare their post-operative infection rates. The findings from this study show that post-operative infection rates were similar between fixation modalities even after accounting for a range of patient- and procedure-related factors.

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“…Multiple studies have evaluated operative times for TKA, with their findings reflecting relative stability in procedure duration over various study periods. 5,6,10,14 Bohl et al evaluated 165,474 patients undergoing TKA between 2006 and 2013 and found a mean operative time of 91.9 AE 32.5 minutes. 14 Similarly, George et al examined 140,199 TKAs performed between 2011 and 2015.…”

Section: Discussionmentioning

confidence: 99%

Operative Times in Primary Total Knee Arthroplasty: Can We Predict the Future Based on Contemporary Nationwide Data

et al. 2019

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Recently, the Centers for Medicare & Medicaid Services announced its decision to review “potentially misvalued” Current Procedural Terminology (CPT) codes, including those for primary total knee arthroplasty (TKA). CPT 27447 is being reevaluated to determine contemporary relative value units for work value, with operative time considered a primary factor in this revaluation. Despite broader indications for TKA, including extension of the procedure to more complex patient populations, it is unknown whether operative times may remain stable in the future. Therefore, the purpose of this study was to specifically evaluate future trends in TKA operative times across a large sample from a national database. The American College of Surgeons National Surgical Quality Improvement Project database was queried from January 1, 2008 to December 31, 2017 to identify 286,816 TKAs using the CPT code 27447. Our final analysis included 140,890 TKAs. Autoregressive integrated moving average forecasting models were built to predict 2- and 10-year operative times. While operative times were significantly different between American Society of Anesthesiologists (ASA) classes 1 and 2 (p = 0.035), there were not enough patients in ASA class 1 to perform rigorous inference. Additionally, operative times were not significantly different between ASA classes 3 and the combined ASA classes 4 and 5 cohort (p = 0.95). Therefore, we were only able to perform forecasts for ASA classes 2 and 3. Operative time was found to be nonstationary for both ASA class 2 (p = 0.08269) and class 3 (p = 0.2385). As a whole, the projection models indicated that operative time will remain within 2 minutes of the present operative time, up to the year 2027. Our projections indicate that operative times will remain stable over the next decade. This suggests that there is a lack of evidence for reducing the valuation of CPT code 27477 based on intraservice time for TKA. Further study should examine operative time trends in the setting of evolving alternative payment models, increasing patient complexity, and governmental restrictions.

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Impact of Operative Time on Adverse Events Following Primary Total Joint Arthroplasty

Cited by 162 publications

References 33 publications

Low Post-Arthroplasty Infection Rate is Possible in Developing Countries: Long-Term Experience of Local Vancomycin Use From A High-Volume Tertiary Knee Center in Iran

Low Post-Arthroplasty Infection Rate is Possible in Developing Countries: Long-Term Experience of Local Vancomycin Use From A High-Volume Tertiary Knee Center in Iran

Postoperative Infection in Cementless and Cemented Total Knee Arthroplasty: A Propensity Score Matched Analysis

Operative Times in Primary Total Knee Arthroplasty: Can We Predict the Future Based on Contemporary Nationwide Data

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