In the September 7, 2016 issue of The Journal, Sutton III et al. report results from a sophisticated analysis of the National Surgical Quality Improvement Program (NSQIP) database confirming that hospital discharge 0 to 2 days after total joint arthroplasty (TJA) is safe in select patients in terms of 30-day major-complication and readmission rates. Large dataset analyses like this represent the next step in confirming what has been going on at the grass-roots level across the world—a movement toward outpatient TJAs and/or very early discharges following those procedures. (See related “Global Forum” article in the July 6, 2016 JBJS.)
This trend has been associated with very high patient satisfaction and low morbidity. The movement away from multiple-day hospital admission and toward rapid discharge to home or alternative postoperative care environments such as hotels or rehabilitation centers has far surpassed the novelty stage and is under way in every major metropolitan area around the world. The trend is a welcome motivation for us to address patient expectations for the postoperative period, which are specifically linked to more judicious use of narcotic medication accompanied by regional and local anesthetic efforts and liberal use of nonsteroidal anti-inflammatory medication. Total joint replacement is the ideal surgical intervention to lead this no- or short-hospitalization movement because of the standardized surgical approaches and requirements for implants, blood-loss management, and thromboprophylaxis.
I envision a time in the not-too-distant future where 80% to 90% of musculoskeletal post-intervention care takes place outside of the hospital environment, a shift that will require efficient use of remote-monitoring technology and continued improvement in post-intervention pain management. Hospitals will then become the setting for very complex events like organ transplantation, appropriate intensive care, and high-level trauma care. This will result in lowering the overall cost of care, improving patient satisfaction (who among us would not rather sleep in our own bed?), and minimizing nosocomial complications.
Marc Swiontkowski, MD
A large retrospective cohort study analyzing nearly 21,000 patients who underwent primary total hip arthroplasty (THA) found that the 61% who received general anesthesia were much more likely to experience an adverse event within 30 days than the 39% who received spinal anesthesia.
Among the adverse events analyzed, the increased risks associated with general anesthesia were more than five-fold for prolonged postoperative ventilator use and cardiac arrest, and more than two-fold for unplanned intubation and stroke. These findings are generally consistent with those of prior research into this question, but the authors say this is “the largest study to date” looking at the comparison.
The authors analyzed data from the National Surgical Quality Improvement Program (NSQIP), and they found that the increased adverse-event risk with general anesthesia held throughout all ranges of preoperative comorbidity. They therefore contend that while many previous studies have found advantages for spinal anesthesia in “medically complex” joint-replacement patients, “this study indicates that these benefits may also extend to patients with fewer medical comorbidities.”
Despite these findings, the authors stress that spinal anesthesia is not risk-free, with the potential (albeit low) for permanent injury to the spinal cord or spinal nerves. They also note that their 30-day postoperative analysis did not capture patient-centered metrics such as postsurgical pain or longer-term functional outcomes.