Publications by authors named "Mark H F Keulen"

8 Publications

  • Page 1 of 1

Rates and Causes of 90-day Complications and Readmissions Following Outpatient Hip and Knee Arthroplasty: A Retrospective Analysis of 525 Patients in a Single Institution.

J Arthroplasty 2021 03 18;36(3):863-878. Epub 2020 Sep 18.

Department of Orthopaedic Surgery, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, the Netherlands.

Background: Outpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist.

Patients And Methods: This retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs ≥1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis.

Results: The complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS ≥1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS ≥1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m2 (vs BMI <25 kg/m2).

Conclusion: SDD following OJA did not result in more complications and hospital readmissions compared to a prolonged hospital stay. The majority of complications and readmissions were due to noninfected wound discharge.
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http://dx.doi.org/10.1016/j.arth.2020.09.019DOI Listing
March 2021

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution.

J Arthroplasty 2020 09 27;35(9):2327-2334.e1. Epub 2020 Apr 27.

Department of Orthopaedics, Zuyderland Medical Center Heerlen and Sittard-Geleen, Geleen, The Netherlands.

Background: Outpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD.

Methods: Five hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients.

Results: One hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001).

Conclusion: An option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.
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http://dx.doi.org/10.1016/j.arth.2020.04.064DOI Listing
September 2020

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty.

J Arthroplasty 2020 08 27;35(8):1986-1992. Epub 2020 Mar 27.

Department of Orthopaedics, Zuyderland Medical Center Heerlen and Sittard-Geleen, BG Geleen, the Netherlands.

Background: It is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.

Methods: Patient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).

Results: One hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.

Conclusion: These results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.
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http://dx.doi.org/10.1016/j.arth.2020.03.034DOI Listing
August 2020

PROMIS PF correlates with HOOS, JR in patients with hip pain.

J Orthop 2020 Sep-Oct;21:58-61. Epub 2020 Feb 7.

Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, 1701 Trinity Street, Austin, TX, 78712, USA.

Background: Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost.

Questions: 1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures?

Methods: In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models.

Results: We found a large correlation between PROMIS PF and HOOS, JR ( 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [β] -3.4; 95% confidence interval [CI] -5.8 to -1.0; P = 0.006 and β -11; 95% CI -17 to -5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (β 4.5; 95% CI 2.2 to 6.8; P < 0.001 and β 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect.

Conclusions: This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jor.2020.01.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036421PMC
February 2020

[Suspected traumatic posterior shoulder luxation].

Ned Tijdschr Geneeskd 2019 10 11;163. Epub 2019 Oct 11.

Zuyderland Medisch Centrum, afd. Orthopedie, Heerlen.

BACKGROUND An obstetric brachial plexus lesion arises during childbirth as a consequence of excessive lateral traction of the neonate's head during shoulder dystocia. A small number of patients do not experience spontaneous recovery and secondary glenohumeral deformities can arise due to rotator cuff imbalance. CASE DESCRIPTION A 34-year-old man of Syrian descent with a history of a conservatively treated right-sided obstetric brachial plexus lesion went to the accident and emergency department (A and E) with acute pain in the right shoulder. Additional X-ray diagnostics suggested a posterior shoulder luxation, but attempts to relocate the glenohumeral joint in A and E failed. An additional CT scan of the shoulders revealed a severe right-sided dysplasia of the glenohumeral joint, with severe retroversion and posterior luxation of a rotated humeral head. After 3 weeks of relative rest through use of a sling and pain relief with an NSAID the pain had diminished and the patient had resumed his daily activities. CONCLUSION Posterior shoulder luxation can occur as a complication of obstetric brachial plexus lesion. Closed reduction is not of any use in these cases. The expertise of a specialized multidisciplinary team is indispensable for providing a patient with obstetric brachial plexus lesion with the best advice on treatment.
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October 2019

PROMIS Physical Function Correlates with KOOS, JR in Patients with Knee Pain.

J Knee Surg 2020 Sep 15;33(9):903-911. Epub 2019 May 15.

Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas.

Using Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computerized adaptive test instead of the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) could reduce question burden for patients with knee pain. We aimed to prospectively determine the correlation between PROMIS PF and KOOS, JR to assess whether PROMIS PF could be a useful alternative measure for both research and clinical care of patients with knee pain. This was a cross-sectional study of 88 patients. We assessed the correlation between PROMIS PF and KOOS, JR using a Pearson's correlation test. Two multivariable linear regression models were used to determine the amount of variation explained by various patient-level factors. There was a strong correlation between PROMIS PF and KOOS, JR ( = 0.74,  < 0.001). KOOS, JR was an independent predictor of PROMIS PF when controlling for patient-level factors (β 0.26;  < 0.001). The results of this study support the idea of using PROMIS PF in place of joint-specific measures such as KOOS, JR for clinical care of patients with knee pain. The level of evidence for this study is Level III.
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http://dx.doi.org/10.1055/s-0039-1688780DOI Listing
September 2020

Does resiliency mediate the association of psychological adaptability with disability and pain in patients with an upper extremity injury or illness?

J Psychosom Res 2019 02 7;117:1-9. Epub 2018 Dec 7.

Department of Surgery and Perioperative Care, Dell Medical School - University of Texas at Austin, 1701 Trinity Street, 78712 Austin, TX, USA. Electronic address:

Objective: Symptom intensity and magnitude of limitations are highly variable for a given nociception and pathophysiology. As psychological determinants are of great influence to physical wellbeing, we assessed the influence of the protective factor measured and labelled as resilience in upper extremity illness.

Methods: One hundred and six patients completed a survey of demographics, the Brief Resilience Scale (BRS), the Psychological Adaptation Scale (PAS), an 11-point ordinal measure of pain intensity, and the PROMIS Physical Function (PROMIS PF) Computer Adaptive Test (CAT). Measures of pain intensity and PROMIS PF were repeated 3 months later. We created mediation models using structural equation modeling (SEM) to assess the mediation effect of BRS on the association of PAS and other confounding variables with disability and pain at initial assessment and 3 months later.

Results: Resiliency does not mediate the association of psychological adaptability with physical limitations and pain intensity at baseline (P = .89 and .82 respectively) or 3 months after enrollment (P = .65 and .72 respectively).

Conclusions: Positive and protective factors promote beneficial resilience mechanisms that strengthen coping responses to pain and disability. In future studies we should either include more patients to improve power and provide more information about the health benefits of resilience or focus more on mood and self-efficacy on symptoms and limitations in patients with musculoskeletal illness.

Level Of Evidence: Prospective, longitudinal cohort study; Level II.
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http://dx.doi.org/10.1016/j.jpsychores.2018.12.002DOI Listing
February 2019

The Effect of the Content of Patient-Reported Outcome Measures on Patient Perceived Empathy and Satisfaction: A Randomized Controlled Trial.

J Hand Surg Am 2018 Dec 8;43(12):1141.e1-1141.e9. Epub 2018 Jun 8.

Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX.

Purpose: The purpose of this study was to examine whether positively or negatively phrased Patient-Reported Outcome Measures (PROMs) prior to a visit with the hand surgeon affect patient perceived empathy and patient satisfaction (Patient-Reported Experience Measures [PREMs]).

Methods: Between June 2017 and July 2017, we enrolled 134 patients who presented to 3 hand surgeons at 2 outpatient offices. They were randomly assigned to 1 of 2 groups: completion of negatively framed questionnaires (Patient Health Questionnaire [PHQ-2], Pain Catastrophizing Scale [PCS-4], and Patient-Reported Outcomes Measurement Information System [PROMIS] depression Computer Adaptive Test [CAT]) or completion of positively framed questionnaires (Pain Self-Efficacy Questionnaire [PSEQ-2]) prior to the visit. At the end of the visit, all patients completed questionnaires on patient-perceived physician empathy and patient satisfaction. Five patients were excluded from the analysis after randomization.

Results: There was no statistically significant differences between groups on patient-perceived physician empathy and patient satisfaction.

Conclusions: Our findings suggest that the content of psychological questionnaires completed prior to the visit does not affect patient satisfaction and perceived empathy recorded after the visit.

Clinical Relevance: Given the degree to which PROMs are influenced by psychosocial factors, and prior evidence that PROMs are primed by negatively framed questionnaires, it is reassuring that negatively framed PROMs did not affect PREMs, but more research is merited.
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http://dx.doi.org/10.1016/j.jhsa.2018.04.020DOI Listing
December 2018
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