Sodhi Nipun, Anis Hiba K, Coste Marine, Ehiorobo Joseph O, Chee Alexander, Freund Benjamin, Sultan Assem A, Moskal Joseph T, Scuderi Giles R, Mont Michael A
Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York.
Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.
J Knee Surg. 2019 Nov;32(11):1040-1045. doi: 10.1055/s-0039-1677790. Epub 2019 Feb 20.
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 ( < 0.001). Mean operative times and LOS were significantly shorter in elective cases compared with nonelective cases (93 vs. 112 minutes, < 0.005; 3 vs. 5 days, < 0.001). Multivariate analysis showed these associations remained significant even after adjusting for potential confounders ( < 0.001). Compared with the nonelective cohort, patients in the elective cohort were more likely to be discharged home (74 vs. 69%, < 0.001). Nonelective patients had higher rates of pneumonia (0.7 vs. 0.3%, = 0.005), organ-space surgical site infections (SSI; 0.4 vs. 0.2%, = 0.004), transfusions (10.9 vs. 6.5%, < 0.001), sepsis (0.6 vs. 0.2%, = 0.001), and septic shock (0.2 vs. 0.1%, = 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.
与非选择性全膝关节置换术（TKA）相比，选择性手术有更多时间进行术前规划，这可能会改善患者的身体状况、修正风险因素并加强患者教育。本研究的目的是：（1）确定全国范围内手术时间的趋势；（2）评估手术类型（选择性或非选择性）与以下方面的关联：（a）手术时间、（b）住院时间（LOS）、（c）出院处置、（d）术后30天并发症、（e）再次手术以及（f）再入院情况。查询了美国外科医师学会国家外科质量改进计划（ACS - NSQIP）数据库中2011年至2016年期间进行的所有初次TKA病例。这产生了209,178例病例，这些病例被分为选择性和非选择性病例。选择性病例是指患者从正常生活环境被送来进行预定手术的病例。使用单因素方差分析（ANOVA）来评估手术时间与手术年份之间的关联。使用针对手术年份和患者因素（年龄、性别、体重指数[BMI]以及美国麻醉医师协会[ASA]评分）进行调整的多变量线性和逻辑回归模型，来评估手术类型与围手术期和术后结果之间的关联。观察到手术时间与手术年份之间存在显著的负相关（<0.001）。与非选择性病例相比，选择性病例的平均手术时间和住院时间显著更短（93分钟对112分钟，<0.005；3天对5天，<0.001）。多变量分析表明，即使在调整了潜在混杂因素后，这些关联仍然显著（<0.001）。与非选择性队列相比，选择性队列中的患者更有可能出院回家（74%对69%，<0.001）。与选择性患者相比，非选择性患者的肺炎发生率更高（0.7%对0.3%，=0.005）、器官腔隙手术部位感染（SSI；0.4%对0.2%，=0.004）、输血率更高（10.9%对6.5%，<0.001）、败血症发生率更高（0.6%对0.2%，=0.001）以及感染性休克发生率更高（0.2%对0.1%，=0.005）。这些关联在多变量逻辑回归分析中仍然显著。本研究表明，术前规划有助于缩短手术时间和住院时间，并降低并发症和再次手术率。除了本研究中确定的直接优势外，潜在的更大影响包括更好的患者预后和降低医疗成本。
