Liu, Jiabin

Background Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. Methods A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. Results Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). Conclusions Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

AbstractFor patients who qualify, simultaneous bilateral total knee arthroplasty (TKA) is a viable option for the treatment of bilateral symptoms. However, the incidence of chronic obstructive pulmonary disease (COPD) has been steadily rising over the past few decades and may impact those who qualify as candidates for bilateral TKA. As such, the aim of this study was to determine the impact of COPD on postoperative outcomes in patients who receive simultaneous bilateral TKA. A retrospective cohort study was conducted utilizing data provided through the American College of Surgeons National Surgical Quality Improvement Program. All patients who had undergone simultaneous bilateral TKA between 2007 and 2016 were identified and further stratified into groups based upon the COPD status. Incidence of adverse events after TKA in the acute postoperative period was evaluated with univariate and multivariate analyses. COPD was found to be an independent risk factor for the development of major (odds ratio [OR]: 2.5; p = 0.015), renal (OR: 5.1; p = 0.02), and thromboembolic complications (OR: 2.5; p = 0.027). In addition, patients with COPD were at increased risk for having an extended hospital length of stay (LOS; p < 0.001) and development of urinary tract infections (p < 0.001). Patients with COPD are at higher risk for development of overall major complications, as well as renal and thromboembolic complications after simultaneous bilateral TKA. Interestingly, patients were not at increased risk for the development of pulmonary or wound complications. When considering a staged versus simultaneous bilateral TKA, surgeons should be aware of the impact COPD status has on the postoperative complication rate.