Abstract
Background:
Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers.
Methods:
We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties [rTHAs] and 445 revision total knee arthroplasties [rTKAs]) performed over four years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions.
Results:
Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day one and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only six patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80).
Conclusion:
While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data supports the notion that modern GA techniques can be successfully used in revision total joint arthroplasty.
Keywords: revision, total hip arthroplasty, total knee arthroplasty, general anesthesia, length of stay, rapid recovery
Introduction
As the aging population seeks more primary joint arthroplasties, the number of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) is expected to increase. Debate exists as to the anesthetic technique for primary arthroplasty. Neuraxial anesthesia has been promoted in several non-randomized studies with lower rates of surgical and postsurgical complications, including less blood loss and lower transfusion rates, shorter length of stay (LOS), lower rates of postoperative delirium, improved early therapy and mobilization rates, lower deep vein thrombosis (DVT) risks, and overall improved 30-day morbidity and mortality1,2,3,4,5. However, patients who have more comorbidities and coagulopathies often undergo general anesthesia (GA). 6 Other factors may favor a general anesthetic in the revision setting, including predicted blood loss, the potential for hemodynamic instability, and the unpredictable length of surgery. Additionally, modern general anesthetics allow for early mobilization with low complication rates for primary TJA.7
There is limited guidance on the preferred anesthesia for joint surgery, and even less so for revision cases. Several studies have tried to answer this question in the past decade, but no definite conclusions have been drawn. Revision cases are more complex and include elderly and less healthy patients, resulting in longer hospital stays and higher costs, making them harder to evaluate.8 Revision cases may also be urgently booked for diagnoses such as fracture, loosening, or dislocation. Additionally, data remains limited on the outcomes of revision TJA using modern GA protocols that employ shorter-acting paralytics and multimodal anesthesia and analgesic regimens.
The purpose of our study was to report the outcomes and complications of modern GA used in a cohort of consecutive patients undergoing revision TJA by fellowship-trained arthroplasty surgeons at a high-volume institution. We hypothesized that early mobilization and discharge are possible with a modern GA protocol without prolonged LOS or excessive complications and readmissions. Secondarily, we aimed to investigate factors that caused a deviation in post-operative outcomes and care, such as the urgency of the case.
Materials and Methods
Study Method
After Institutional Review Board approval, a retrospective review of all revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) procedures performed at a high-volume tertiary referral center from June 1, 2015, to June 1, 2019, was conducted. We queried our electronic medical records (EMR) for Current Procedural Terminology (CPT) codes 27134 (rTHA, full), 27137 (rTHA, acetabular), 27138 (rTHA, femoral), 27486 (rTKA, one component), and 27487 (rTKA, full). Patients were subcategorized based on their procedure type. Demographic and baseline information was then obtained and included age, sex, race, body mass index (BMI), smoking status, health literacy score, American Society of Anesthesiologists (ASA) score, and payer status. The surgical and postsurgical data points captured included the performing surgeon; time from admission to the procedure; procedure times; total time in the operating room (OR); time in the post-anesthesia care unit (PACU); time from procedure to discharge; total LOS; physical therapy (PT) participation on the day of surgery; and 90-day complications, readmissions, reoperations, and mortality events. Complications included major cardiovascular events, blood transfusions, transfers to an intensive care unit (ICU), delirium, postoperative nerve palsy, nausea, prolonged intubation, hematoma or hemarthrosis, venous thromboembolism (VTE), and periprosthetic joint infection (PJI). Next, records of all patients for whom a complication noted above was captured were individually reviewed to confirm the validity of the data acquired. Finally, records of patients who failed to undergo revision total joint arthroplasty (TJA) on the day of their admission, who failed to participate in PT on the day of surgery, who were not discharged on postoperative day (POD) #1, and/or who were readmitted within ninety (90) days of the revision procedure were individually reviewed to confirm the validity of the data acquired and to ascertain the cause.
Study Cohorts
After exclusions, our final sample included 850 revision TJA cases performed by fellowship-trained surgeons under general anesthesia from June 1, 2015 to June1, 2019 (Figure 1).
Figure 1.
Flow diagram of inclusion and exclusion criteria of the study sample. THA, total hip arthroplasty; TKA, total knee arthroplasty; PJI, periprosthetic joint infection
Of the 850 procedures that utilized GA, there were 405 (48%) rTHAs and 445 (52%) rTKAs performed. The rTHA patients included those who underwent arthroplasty of both acetabular and femoral components (n = 231), an acetabular component only (n = 85), a liner/head (n = 24), and a femoral component only (n = 65). The rTKA patients included those who underwent arthroplasty of both femoral and tibial components (n = 343), femoral component only (n = 11), polyethylene exchange (n = 82), and tibial component only (n = 9). The ASA score did not differ significantly between those who had rTHA and rTKA (P = 0.051). Additional demographic data for all revision types are provided in Table 1.
Table 1.
Demographics and baseline characteristics of patients who underwent revision THA and/or TKA from 2015-2019.a
| Demographic/Baseline Characteristic | Revision THA | Revision TKA | All Surgeries |
|---|---|---|---|
| Total Procedures, n (%) | 405 (48) | 445 (52) | 850 (100) |
| Age (years), n (%) | |||
| < 55 | 88 (22) | 67 (15) | 155 (18) |
| 55 - 64 | 87 (21) | 147 (33) | 234 (28) |
| 65 - 74 | 112 (28) | 136 (31) | 248 (29) |
| > 75 | 118 (29) | 95 (21) | 213 (25) |
| Sex, n (%) | |||
| Men | 177 (44) | 165 (37) | 342 (40) |
| Women | 228 (56) | 280 (63) | 508 (60) |
| Race, n (%) | |||
| American Indian or Alaskan Native | 1 (0.2) | 1 (0.1) | |
| Asian | 1 (0.2) | 1 (0.1) | |
| Black or African American | 41 (10) | 71 (16) | 112 (13) |
| Native Hawaiian or Other Pacific Islander | |||
| White | 352 (87) | 371 (83) | 723 (85) |
| Other | 10 (2.5) | 2 (0.4) | 12 (1.4) |
| Not reported | 1 (0.2) | 1 (0.1) | |
| BMI, n(%) | |||
| Underweight (<18.50 kg/m2) | 2 (0.5) | 1 (0.2) | 3 (0.4) |
| Normal (18.50 - 24.99 kg/m2) | 95 (23) | 43 (10) | 138 (16) |
| Overweight (25.00 - 29.99 kg/m2) | 136 (34) | 106 (24) | 242 (28) |
| Obese Class I (30.00 - 34.99 kg/m2) | 101 (25) | 130 (29) | 231 (27) |
| Obese Class II (35.00 - 39.99 kg/m2) | 44 (11) | 89 (20) | 133 (16) |
| Morbidly Obese (≥40 kg/m2) | 16 (4) | 64 (14) | 80 (9) |
| Not reported | 11 (2.7) | 12 (2.7) | 23 (2.7) |
| Smoking Status, n (%) | |||
| Current | 62 (15) | 42 (9) | 104 (12) |
| Quit | 117 (29) | 120 (27) | 237 (28) |
| Never | 224 (55) | 280 (63) | 504 (59) |
| Not reported | 1 (0.2) | 1 (0.2) | 2 (0.2) |
| Single Question Health Literacy Screening Scoreb, n (%) | |||
| Adequate Health Literacy (1-2) | 240 (59) | 287 (64) | 527 (62) |
| Inadequate Health Literacy (≥3) | 35 (8.6) | 8 (6.7) | 65 (7.6) |
| Not reported | 130 (32) | 128 (29) | 258 (30) |
| ASA Physical Status Category, n (%) | |||
| 1, Healthy | 8 (2) | 5 (1.1) | 13 (1.5) |
| 2, Mild Systemic Disease | 163 (40) | 188 (42) | 351 (41) |
| 3, Severe Systemic Disease | 216 (53) | 243 (55) | 459 (54) |
| 4, Incapacitating Disease | 18 (4.4) | 9 (2) | 27 (3.2) |
| Payor Status, n (%) | |||
| Medicare | 280 (69) | 287 (64) | 567 (67) |
| Medicaid | 23 (5.7) | 15 (3.4) | 38 (4.5) |
| Other Government | 5 (1.2) | 13 (2.9) | 18 (2.1) |
| Private Insurance | 96 (24) | 129 (29) | 225 (26) |
| Uninsured | 1 (0.2) | 1 (0.2) | 2 (0.2) |
| Discharge Destination | |||
| Skilled Nursing Facility | 60 (14.8) | 37 (8.3) | 194 (11.4) |
| Left Against Medical Advice | 1 (0.2) | 2 (0.1) | |
| Home or Self Care | 313 (77.3) | 392 (88.1) | 1410 (82.9) |
| Federal Hospital | 1 (0.2) | 2 (0.1) | |
| Custodial Care Facility | 1 (0.2) | 2 (0.1) | |
| Rehab Facility | 13 (3.2) | 5 (1.1) | 36 (2.1) |
| Home-Health Care Svc | 14 (3.5) | 10 (2.2) | 48 (2.8) |
| Expired | 1 (0.2) | 1 (0.2) | 4 (0.2) |
| Short Term Hospital | 1 (0.2) | 2 (0.1) |
Percentages may not sum to 100 dueto rounding
Patients answered “How confident are you filling out medical forms by yourself?” with one of the following: 1-Extremely, 2-Quite a bit, 3-Somewhat, 4-A little, 5-Not at all
| BMI, Body Mass Index; ASA, American Society of Anesthesiologists; THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty
At our institution, the care for primary and revision total hip and knee arthroplasty cases has followed a structured care pathway since July 2015. 9 Our anesthesia team aimed to minimize narcotic use, utilize intravenous anesthesia methods for maintenance, and preserve motor function for early physical therapy by employing a multimodal analgesic strategy. Our team employed an approach identical to the perioperative analgesic and anesthetic protocols from our prior series utilizing general anesthesia.7
Revision THA and TKA Protocols
All patients initially seen at our tertiary referral outpatient clinic went through our standard optimization of modifiable risk factors protocols before revision TJA. 10 To evaluate the “urgency” of a case as a confounding variable, the non-elective rTHAs were defined as those that were performed after the day of admission; 94 of the rTHAs were done urgently (23.2% of rTHAs). Only 5.6% of the rTKAs were non-elective by our definition, so we did not analyze them separately. Many of the patients presented with acute conditions, so preoperative medical modifications were not feasible.
The rate of cases performed on the day of admission was 76.8% for rTHA, 94.4% for rTKA, and 86% for all revisions. Reasons for a delay in surgery included admission for another procedure, medical optimization, awaiting PJI workup, induction-related complications, and planned delays due to surgeon and/or OR availability. Patients who had a delay to surgery were at a significantly higher risk of discharging after POD #1 compared to those whose procedure was performed on the day of admission (Relative Risk (RR) 4.03 for rTHA (95% Confidence Interval (CI) 3.12 to 5.21), 4.08 for rTKA (95% CI 2.89 to 5.75), and 4.24 (95% CI 3.51 to 5.11) for all revisions).
Our mobilization revision TJA process was the same physical therapy (PT) protocol used by our primary TJA publication. 7 For those patients staying > 1 day, they continued to work with physical therapy twice daily, as allowed by their associated medical condition.
Outcomes
The primary outcome measured was LOS. The secondary outcomes measured included: 1) incidence of PT on POD #0; 2) incidence of discharge on POD #1; 3) procedure time, 4) time in OR; 5) time in PACU; 6) complications; 7) 90-day readmissions; and 8) 90-day mortality.
Data Analyses
Continuous variables were analyzed using Student’s t-tests, whereas categorical variables were compared with either Fisher exact tests or the Chi-square tests when comparing two or more outcomes between revision THA and TKA subjects. Statistical significance was set at a P-value of < 0.05. Because so few patients received SA during this period, we did not perform a direct statistical comparison to TJA GA cases.
Results
Outcomes
The average LOS was 2.5 days (SD 3.6) for rTHA, 1.7 days (SD 1.5) for rTKA, and 2.1 days (SD 2.8) for all revisions (P < 0.0001). The rate of participation in PT on the same day of surgery (POD #0) was 60% for rTHA, 76.2% for rTKA, and 68.5% for all revisions (Table 2). Overall, the most common cause for lack of participation in PT on POD #0 was a later surgery time, which led to the patient being discharged from PACU at a time when PT services were not available (91 of 267). Other notable causes included excessive pain, lethargy, and syncope due to hypotension or acute blood loss anemia (Table 3).
Table 2.
Surgery characteristics for revision THA and TKA from 2015-2019.
| Revision THA |
Revision TKA |
All Revisions |
|
|---|---|---|---|
| Characteristic | n = 405 | n = 445 | n = 850 |
| Length of stay (d), Mean ± SD | 2.5 ± 3.6 | 1.7 ± 1.5 | 2.1 ± 2.8 |
| Incidence of surgery ≥ 1 day after admission | 94 (23.2) | 25 (5.6) | 119 (14) |
| Incidence of surgery on the day of admission | 311 (76.8) | 420 (94.4) | 731 (86) |
| Incidence of PT on POD #0, n (%) | 243 (60) | 339 (76.2) | 582 (68.5) |
| Incidence of discharge on POD #1, n (%) | 274 (67.7) | 358 (80.4) | 632 (74.4) |
| Procedure time (min), Mean ± SD | 94 ± 34 | 90 ± 35 | 92 ± 35 |
| Time in OR (min), Mean ± SD | 147 ± 40 | 136 ± 41 | 142 ± 41 |
| Time in PACU (min), Mean ± SD | 131 ± 65 | 130 ± 91 | 130 ± 80 |
OR, Operating Room; PACU, Post-Anesthesia Care Unit; POD, Postoperative Day; PT, Physical Therapy; THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty
Table 3.
Reasons for inability to participate in same-day physical therapy in revision THA and TKA from 2015 - 2019.a
| Incidence of no PT on POD #0, n (%) |
|||
|---|---|---|---|
| Revision THA |
Revision TKA |
All Revisions |
|
| Primary cause | n = 405 | n = 445 | n = 850 |
| Acute blood loss anemia/hypotension/syncope | 10 (2.5) | 2 (0.4) | 12 (1.4) |
| Brace unavailable | 3 (0.7) | 3 (0.4) | |
| Cardiac Event | 1 (0.2) | 1 (0.2) | 2 (0.2) |
| Delirium | 5 (1.2) | 5 (0.6) | |
| Excessive pain | 12 (3) | 12 (2.7) | 24 (2.8) |
| Hematoma | 1 (0.2) | 1 (0.1) | |
| Hypertension | 1 (0.2) | 1 (0.1) | |
| ICU transfer | 5 (1.2) | 1 (0.2) | 6 (0.7) |
| Late surgery/PACU discharge | 56 (13.8) | 35 (7.9) | 91 (10.7) |
| Lethargy | 8 (2) | 9 (2) | 17 (2) |
| Mortality | 1 (0.2) | 1 (0.1) | |
| Nausea/Vomting | 1 (0.2) | 3 (0.7) | 4 (0.5) |
| No PT order | 1 (0.2) | 1 (0.1) | |
| Not required | 2 (0.4) | 2 (0.2) | |
| Patient refusal | 5 (1.2) | 3 (0.7) | 8 (0.9) |
| Physical therapist did not attempt | 1 (0.2) | 1 (0.2) | 2 (0.5) |
| Surgeon’s orders | 8 (2) | 2 (0.4) | 10 (1.2) |
| Undetermined | 44 (10.9) | 33 (7.4) | 77 (9.1) |
| All | 161 (39.8) | 106 (23.8) | 267 (31.4) |
Percentages may not sum appropriately due to rounding
ICU, Intensive Care Unit; PACU, Post-Anesthesia Care Unit; POD, Post-op Day; PT, Physical Therapy; THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty
The rate of discharge on POD #1 was 67.7% for rTHA, 80.4% for rTKA, and 74.4% for all revisions. Overall, the most common causes for discharge after POD #1 were issues with placement or discharge to a post-acute care facility requiring a minimum LOS of 3 days, poor progress in PT, acute blood loss anemia requiring blood transfusion, and cardiovascular events requiring medical management. The incidences of all causes of discharge after POD#1 are listed in Table 4.
Table 4.
Causes for discharge after POD #1 in revision THA and TKA from 2015-2019.a
| Incidence of discharge after POD #1, n (%) |
|||
|---|---|---|---|
| Revision THA |
Revision TKA |
All Revisions |
|
| Primary Cause | n = 405 | n = 445 | n = 850 |
| Surgery-related | |||
| Acute Blood Loss Anemia | 20 (4.9) | 5 (1.1) | 25 (2.9) |
| Bleeding | 1 (0.2) | 1 (0.1) | |
| Dislocation | 1 (0.2) | 1 (0.2) | 2 (0.2) |
| Embolism | 2 (0.5) | 2 (0.2) | |
| Excessive Pain | 2 (0.5) | 8 (1.8) | 10 (1.2) |
| Foot Drop | 1 (0.2) | 1 (0.2) | 2 (0.2) |
| Hematoma | 1 (0.2) | 1 (0.1) | |
| Infection Workup | 1 (0.2) | 4 (0.9) | 5 (0.6) |
| Lower Extremity Swelling | 1 (0.2) | 1 (0.1) | |
| Periprosthetic Fracture | 2 (0.5) | 2 (0.2) | |
| Slow Progression in Physical Therapy | 30 (1.5) | 15 (3.4) | 45 (5.3) |
| Wound Issue | 3 (0.7) | 7 (1.6) | 10 (1.2) |
| Anesthesia-related | |||
| Delirium | 5 (1.2) | 5 (0.6) | |
| Dysphagia | 1 (0.2) | 1 (0.1) | |
| Ileus | 1 (0.2) | 1 (0.1) | |
| Respiratory Failure | 4 (0.9) | 4 (0.5) | |
| Voiding Dysfunction | 3 (0.7) | 3 (0.4) | |
| Medicine-related | |||
| Cardiovascular Event | 12 (3) | 11 (2.5) | 23 (2.7) |
| Electrolyte Derangement | 1 (0.2) | 1 (0.1) | |
| Endocrine Issue | 2 (0.5) | 2 (0.2) | |
| Gastrointestinal Issue | 1 (0.2) | 1 (0.1) | |
| Oncological Treatment | 2 (0.5) | 2 (0.2) | |
| Pulmonary Issue | 1 (0.2) | 3 (0.7) | 4 (0.5) |
| Renal Issue | 6 (1.5) | 2 (0.4) | 8 (0.9) |
| Other | |||
| Placement Issue/Skilled Nursing Facility | 30 (7.4) | 20 (4.5) | 50 (5.9) |
| Psych Episode | 1 (0.2) | 1 (0.1) | |
| Separate-site Wound Care | 3 (0.7) | 3 (0.4) | |
| Separate-site Surgery | 1 (0.2) | 1 (0.1) | |
| Trauma | 1 (0.2) | 1 (0.1) | |
| Undetermined | 1 (0.2) | 1 (0.1) | |
| All | 131 (32.3) | 87 (19.6) | 218 (25.6) |
Percentages may not sum appropriately due to rounding
THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty
The average procedure times, time in OR, and time in PACU for rTHA and rTKA are depicted in Table 2. On average, significantly more time was spent in the room for induction and reversal of anesthesia and patient positioning (nonoperative in-room time) in rTHA (53 minutes, SD 15) versus rTKA (46 minutes, SD 14) [P < 0.001]. However, the procedure times did not significantly differ between rTHA (94 minutes, SD 34) and rTKA (90 minutes, SD 35) [P = 0.09].
The most common immediate postoperative complications were acute blood loss anemia requiring transfusion, cardiovascular events, delirium, ICU transfer, and postoperative nausea and/or vomiting (Table 5). Overall, six of the rTKAs and 5 of the rTHAs were transferred to the ICU. The rTKAs that were transferred to the ICU were all due to respiratory distress and/or hypotension. Of the rTHAs, four were transferred for cardiovascular concern, and the last patient was transferred for immediate post-operative observation due to a hemoglobin of 4.2 and an INR > 10 preoperatively. The overall rate of PJI was 5.8%, hematoma and/or was hemarthrosis 0.9%, and VTE was 0.4%.
Table 5.
Complications in revision THA and TKA from 2015-2019.a
| Incidence of complications, n (%) |
|||
|---|---|---|---|
| Revision THA |
Revision TKA |
All Revisions |
|
| Complications | n = 405 | n = 445 | n = 850 |
| Blood transfusion, n (%) | 90 (22.2) | 16 (3.6) | 106 (12.5) |
| Cardiovascular Event, n (%) | 15 (3.7) | 15 (3.4) | 30 (3.5) |
| Delirium, n (%) | 17 (4.2) | 6 (1.3) | 23 (2.7) |
| ICU Transfer, n (%) | 5 (1.2) | 6 (1.3) | 11 (1.3) |
| Nerve palsy | 5 (1.2) | 1 (0.2) | 6 (0.6) |
| PONV, n (%) | 9 (2.2) | 8 (1.8) | 17 (2) |
| Prolonged intubation, n (%) | 1 (0.2) | 3 (0.7) | 4 (0.5) |
| Ninety-day | |||
| Hematoma/Hemarthrosis, n (%) | 9 (2.2) | 3 (0.7) | 12 (1.1) |
| Mortality, n (%) | 7 (1.7) | 2 (0.4) | 9 (1.1) |
| Periprosthetic joint infection, n (%) | 21 (5.2) | 28 (6.3) | 49 (5.8) |
| Readmissiona, n (%) | 56 (13.8) | 40 (9) | 96 (11.3) |
| Medical treatment, n (%) | 10 (2.5) | 6 (1.3) | 16 (1.9) |
| Same joint reoperation, n (%) | 46 (11.4) | 34 (7.6) | 80 (9.4) |
| Venous thromboembolism, n (%) | 3 (0.7) | 0 (0) | 3 (0.4) |
Percentages may not sum appropriately due to rounding
ICU, Intensive Care Unit; PONV, Postoperative nausea/vomiting THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty
Overall, 96 patients (11.3%) were readmitted within 90 days for either reoperation of the same joint (n = 80, 9.4%) or medical management of new issues (n = 16, 1.9%). Indications for reoperation of the same joint included PJI, dislocation, wound dehiscence, hematoma or hemarthrosis, hardware failure, periprosthetic fracture, contracture, and arthrofibrosis. The 90-day overall mortality rate was 1.1% (n = 9). There was one death that occurred perioperatively due to cardiac arrest secondary to a massive fat embolism. There were two adverse events that occurred after discharge and were associated with comorbid lung cancer and severe hypotension, ultimately leading to pulseless electrical activity. The cause of death remains unknown in the other six cases.
Furthermore, the average postsurgical LOS for planned cases was 2.03 (SD 2.42) versus 4.01 (SD 3.32) days for unplanned cases (P = 0.0001). Many of the non-elective rTJA cases did not have early mobilization, with only 13 of 94 cases receiving physical therapy on POD #0; alternatively, 252 of 311 cases of the planned rTJA received PT on POD #0. The relative risk of not participating with PT on POD#0 was 4.54 for the unplanned versus planned cases (P < 0.0001). The urgency of the failed TJA cases limited preoperative optimization, explaining the deviations from standard care pathways. Half of the 94 unplanned revision cases were discharged to home, while the other half had to be discharged to a post-acute care facility. In comparison, only 24% of the 124 subjects who did not leave POD #1 after their planned revisions required post-acute care placement, and these were all due to not clearing physical therapy to safely discharge home.
Standard Care Pathway and Patients Affected by GA
Out of the 850 patients in the study, 387 (45.5%) followed a standard care pathway (defined as participation with PT on POD #0 and discharge on POD #1) and remained free of a 90-day complication or readmission. There were 463 out of 850 patients (54.5%) who deviated from this pathway and/or experienced a 90-day complication or readmission. Overall, 19% (87 of 463) of subjects experienced an event that could be reasonably associated with the use of GA. The events we deemed likely or possibly related to GA included delirium, lethargy, nausea and vomiting, shortness of breath, pain, urinary retention, perioperative or PACU cardiac events, seizures, and syncope.
Discussion
This retrospective study showed that most revision TJA patients who received modern GA at our institution could participate in physical therapy on the day of surgery and discharge on POD #1. Many of the patients who did fall into our standard recovery pathway were urgent, unplanned rTHA cases. These unscheduled and urgent cases accounted for nearly 25% of the rTHA causes, making it a confounding variable by causing the average overall LOS and rates of postoperative complications to increase. Second, the data revealed that all patients had low rates of postoperative complications following the procedure with GA, as 9.4% were re-admitted for operation on the same joint and 1.9% were readmitted within 90 days for a new complication. Overall, our results suggest that in a high-volume revision TJA center, modern GA practices can be a safe and effective anesthetic option when paired with a rapid recovery protocol.
Ultimately, the arthroplasty community has not yet reached a unanimous agreement regarding the preferred anesthetic technique for TJA or rTJA, but GA and SA are the two most used in the United States today. 11 The utilization of SA for hip fracture surgery has increased by 50 percent between 2007 and 2017. 12 Institutions that favor SA argue that it is safer since it eliminates the need for intubation and involves fewer medications. 13 Additionally, spinal anesthesia is frequently employed as an alternative for patients who have relative contraindications to general anesthesia, such as those who have heart failure, severe valvular problems, or pulmonary disease. 14 However, spinal anesthesia is also associated with side effects such as urinary retention, respiratory depression, hypotension secondary to sympathetic blockade, and epidural hematoma. 15
We have previously published data on primary TJA outcomes with GA at our institution in response to an increasing number of publications in support of SA over GA. 7 Wilson et al. surveyed the American College of Surgeons National Surgical Quality Improvement Program.(NSQIP) database and showed that those receiving GA for rTHAs had higher rates of readmission and mortality, ORs of 1.49 and 3.72, respectively. Owen et al. retrospectively evaluated rTKAs at their institution from 2001 to 2016 and found a shorter average length of stay following SA versus GA, 4.0 versus 4.6 days. However, each of these studies has specific limitations that should be considered before conclusions are drawn. Wilson et al.’s survey of the national database evaluates data from many different types of institutions. Although rates of spinal anesthesia for rTJAs have increased recently, this increase has mostly been seen in large academic institutions that have more fellowship-trained arthroplasty surgeons and a higher volume of rTJAs.19 Therefore, this level of experience with rTJAs is arguably a major confounding variable affecting patient outcomes. Alternatively, the study by Owen et al. compares both techniques at a single institution, with 66% of the cases using general anesthesia and 34% using spinal anesthesia. 17 The cases were matched based on BMI, age, and sex; however, they did not account for the factors that affect the decision of type of anesthesia, so the outcomes cannot be solely attributed to the anesthetic choice. Therefore, these observational studies and similar ones have important confounding variables for their implications.
Although there are no major randomized control trials (RCTs) to date for evaluating anesthetic choice for rTJAs, Neuman et al. published an RCT in 2021 that evaluated the outcomes of spinal and general anesthesia for treating hip fractures. 18 Notably, they found no significant difference in the incidence of patients unable to walk independently at 60 days (15.2% in the spinal anesthesia group and 14.4% in the general anesthesia group) and mortality within 60 days (3.9% in the spinal anesthesia group and 4.1% in the general anesthesia group). 18 This suggests that the choice between SA and GA may have comparable outcomes for revision total joint arthroplasty, although more research specific to rTJAs is needed to reach a definitive consensus.
We categorized cases as urgent or non-urgent based on a predetermined definition. Some publications have stratified revision cohorts according to indications, such as infection, fracture, dislocation, or equipment failure. Abram et al. found that in an analysis of rTKA from 1997 to 2017 identified by the National Hospital Episode Statistics Revision, elective rTKAs were associated with a 90-day rate of mortality of 0.44% compared to urgent rTKAs (defined as the revisions done for periprosthetic infection and periprosthetic fractures), which had a mortality rate of 2.04 and 5.25%, respectively. 19 Sams et al. determined in a retrospective study at their institution that there was a significant difference in the length of stay for those receiving elective or non-elective rTHA, with an average LOS of 3.8 versus 8.3 days. 20 These studies support separately analyzing elective and non-elective rTJAs due to the confounding factor of urgency in TJA procedures.
Potential Limitations
Our study is potentially limited by several factors, such as the lack of comparison of GA with SA at our institution. Additionally, rTJA patients are more complex than primary TJA patients, causing more variability in data. The generalizability of this study could also be limited due to the rapid recovery protocols specific to our institution. Furthermore, our study is retrospective and may not capture complications and readmissions to other hospitals.
Conclusion
Despite limitations of generalizability, the data and conclusions from this study should be viewed considering recent retrospective studies that purport the superiority of spinal anesthesia. Given the absence of randomized control trials for rTJAs, it is imperative to consider existing evidence, particularly at our institution, which does not provide substantial evidence against the use of GA in ambulatory revision joint arthroplasty. This study shows that a general anesthesia protocol has been a successful choice for rTJAs at our institution. Each type of anesthesia carries its own risks and possible complications, and the decision of which to choose should be made with a multidisciplinary approach according to the patient and clinical care team in the absence of randomized control trials that definitively suggest one over the other.
Supplementary Material
Acknowledgements:
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number P20GM125503. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. In addition, the Bill and Betty Petty Research Fund at the University of Arkansas for Medical Sciences supported this work.
Footnotes
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