2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients

Unplanned emergency department visits within 90 days of hip hemiarthroplasty for osteoporotic femoral neck fractures: Reasons, risks, and mortalities

Objectives

Bipolar hemiarthroplasty is commonly performed to treat displaced femoral neck fractures in osteoporotic patients. This study aimed to assess the occurrence and outcomes of unplanned return visits to the emergency department (ED) within 90 days following bipolar hemiarthroplasty for displaced femoral neck fractures.

Methods

The clinical data of 1322 consecutive patients who underwent bipolar hemiarthroplasty for osteoporotic femoral neck fractures at a tertiary medical center were analyzed. Data from the patients' electronic medical records, including demographic information, comorbidities, and operative details, were collected. The risk factors and mortality rates were analyzed.

Results

Within 90 days after surgery, 19.9% of patients returned to the ED. Surgery-related reasons accounted for 20.2% of the patient's returns. Older age, a high Charlson comorbidity index score, chronic kidney disease, and a history of cancer were identified as significant risk factors for unplanned ED visits. Patients with uncemented implants had a significantly greater risk of returning to the ED due to periprosthetic fractures than did those with cemented implants (P = 0.04). Patients who returned to the ED within 90 days had an almost fivefold greater 1-year mortality rate (15.2% vs 3.1%, P < 0.001) and a greater overall mortality rate (26.2% vs 10.5%, P < 0.001).

Conclusions

This study highlights the importance of identifying risk factors for unplanned ED visits after bipolar hemiarthroplasty, which may contribute to a better prognosis. Consideration should be given to the use of cemented implants for hemiarthroplasty, as uncemented implants are associated with a greater risk of periprosthetic fractures.

Computer-Assisted Surgery in Total Knee Arthroplasty: Our Experience

Background

Total knee arthroplasty (TKA) is a reliable orthopedic procedure for knee osteoarthritis with long-term success rates of 90% after 15 years. Computer-assisted surgery (CAS) has been developed to improve the accuracy of the alignment and orientation of the components in TKA.

Methods

A prospective study involving 103 subjects who underwent CAS-TKA was conducted over a 3-year period. Subjects were assessed for pre- and post-operative varus and valgus deformity, BMI, comorbidities, and Knee Society Score (KSS). Outcome measures of post-operative KSS, post-operative alignment, and hospital stay were examined by Spearman correlation coefficients. Categorical outcomes of complication and secondary procedures were compared by chi-squared test and odds ratio.

Results

The study considered 103 TKA patients with a mean ± SD age of 63.7 ± 8.4 years (33-88 years). Unilateral knee replacement was performed on 56 patients (54.3%) and remaining 47 (45.6%) had simultaneous bilateral TKA. Forty (34.8%) patients were obese, and severe pre-operative deformity (> 15°) was observed in 47 (31.3%) patients. Mean coronal alignment of the knee joint was 91.33° (SD: 90.69° valgus-88.92° varus). The mean post-operative KSS noted in obese and non-obese subjects were 93.43 (84-98) and 94.76 (85-98) respectively. Post-operative KSS for knees with severe deformity was 94.08 (80-98), while it was 95.76 (83-98) in those with mild to moderate deformities.

Conclusion

The study confirms that navigation in CAS-TKA consistently achieved coronal alignment of the knee joint within ± 3°, irrespective of the patient BMI and degree of deformity.

The Financial Burden of Patient Comorbidities on Total Hip Arthroplasties-A Matched Cohort Analysis of High Comorbidity Burden and Non-High Comorbidity Burden Patients

BACKGROUND

The impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB).

METHODS

We retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group).

RESULTS

Total (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049).

CONCLUSIONS

Increased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations.

LEVEL OF EVIDENCE

III.

Higher Risk of Reoperation after Total Knee Arthroplasty in Young and Elderly Patients

As outcomes and survivorship improve, total knee arthroplasty (TKA) has expanded into broader age groups. The purpose of this study is to analyze the impact of age on TKA outcomes using the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020. Patients were categorized into young (40-49 years), middle (50-79 years), and elderly (80-89 years) groups. Findings reveal notable differences across age groups. The young cohort had the highest BMI, smoking incidence, and steroid use, while the elderly group exhibited a higher prevalence of comorbidities. Young patients experienced shorter hospital stays (p < 0.001) but longer operative times (p < 0.001), and outpatient surgery was most common in the middle age group. Multivariable regression demonstrated that the elderly group faced increased risks of pneumonia (p < 0.001), acute renal failure (p < 0.001), stroke (p < 0.001), cardiac arrest (p < 0.001), and transfusions (p < 0.001), while both young and elderly patients had higher 30-day reoperation risks (youngest cohort, 1.4% and elderly cohort 1.3% (p < 0.001)). In summary, elderly patients undergoing TKA are at the highest risk for medical complications, while young patients are more likely to undergo inpatient surgery, experience reoperations, and have longer operative times. This study underscores the importance of age-specific counseling for TKA patients and contributes valuable insights into the evolving landscape of knee replacement surgery.

Epidemiological Characteristics and Trends of Primary Hip Arthroplasty in Five Tertiary Hospitals: A Multicenter Retrospective Study

OBJECTIVE

The number of primary hip arthroplasty (PHA) has increased sharply in recent years. Whether the epidemiological characteristics and trends of PHA have changed are unknown. This study aims to analyze the epidemiological characteristics and trends of those patients are urgent for public health institutions.

METHODS

The data of patients who underwent PHA in five tertiary hospitals from January 2011 to December 2020 were retrospectively reviewed. A total of 21,898 patients were included, most of whom were aged 60-69 years (25.1% males and 31.5% females). According to the hospitalization date, the patients were divided into two groups (Group A and Group B). The patients admitted between January 2011 and December 2015 were designated as Group A (7862), and those admitted between January 2016 and December 2020 were designated as Group B (14036). The patient data of the two groups, including sex, age, disease causes, body mass index (BMI), comorbidities, surgical procedures, hospital stay duration, and hospitalization costs, were analyzed by Pearson chi-Square test, Student t test or Mann-Whitney U test.

RESULTS

More women were included in Group B than in Group A (58.5% vs 52.5%, P < 0.001). The mean age of Group B was less than that of Group A (62.27 ± 14.77 vs 60.69 ± 14.44 years, P < 0.001). Femoral head necrosis was the primary pathogenic factor in both groups, with a higher proportion in Group B than in Group A (55.5% vs 45.5%, P < 0.001). Significant differences were found between the two groups in BMI, comorbidities, surgical procedures, hospital stay duration, and hospitalization costs. Total hip arthroplasty (THA) was the most common surgical procedure in both groups, with a higher proportion in Group B than in Group A (89.8% vs 79.3%, P < 0.001). The proportion of patients with one or more comorbidities was significantly higher in Group B than in Group A (69.2% vs 59.9%, P < 0.001). In addition, Group B had a shorter hospital stay duration and higher hospitalization costs than Group A.

CONCLUSION

Femoral head necrosis was the primary etiology for PHA in this study, followed by femoral neck fracture and hip osteoarthritis. Patients who underwent PHA exhibited a higher percentage of femoral head necrosis; underwent THA more often; and had larger BMIs, more comorbidities, higher medical costs, and younger age in the past decade.

Outcomes of the Anterior-Based Muscle-Sparing Approach in Elective Total Hip Arthroplasty in Nonagenarians

Background

As the population ages, total hip arthroplasty has become more common in elderly patients including patients over the age of 90 years. Efficacy in this age group has been established, though literature regarding safety of total hip arthroplasty in nonagenarians is mixed. The anterior-based muscle-sparing (ABMS) approach, which exploits the intermuscular plane between the tensor fasciae latae and the gluteus medius, has proposed benefits of fast recovery, excellent stability, and reduced bleeding and may be adventitious among elderly, more fragile patients.

Methods

A total of 38 consecutive nonagenarians undergoing elective, primary total hip arthroplasty via the ABMS approach for any indication from 2013 to 2020 were identified, and information regarding operative outcomes and patient-reported outcomes was gathered from review of medical records and our institutional joint replacement outcomes database.

Results

Included patients ranged from 90 to 97 years of age with the majority classified as American Society of Anesthesiologists score 2 (50%) or American Society of Anesthesiologists 3 (47.4%). The mean operative time was 74.6 minutes ± 13.6 minutes. Of all patients, 5 required a transfusion, 2 patients were readmitted within 90 days, and there were no major complications. The mean hospital length of stay was 2.8 days ± 0.8 days with 22 patients (57.9%) discharged to a skilled nursing facility. Limited patient-reported outcomes data showed statistically significant improvements in most outcomes scores at 6 months to 1 year postoperatively compared to preoperative scores.

Conclusions

The ABMS approach is safe and effective in nonagenarians who may benefit from decreased amounts of bleeding and recovery times associated with the ABMS approach, which is evident from the low complication rates, relatively short hospital lengths of stay, and acceptable transfusion rates compared to previous studies.

Can extant comorbidity indices identify patients who experience poor outcomes following total joint arthroplasty?

INTRODUCTION

It is uncertain if generic comorbidity indices commonly used in orthopedics accurately predict outcomes after total hip (THA) or knee arthroplasty (TKA). The purpose of this study was to determine the predictive ability of such comorbidity indices for: (1) 30-day mortality; (2) 30-day rate of major and minor complications; (3) discharge disposition; and (4) extended length of stay (LOS).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent elective THA (n = 202,488) or TKA (n = 230,823) from 2011 to 2019. The American Society of Anesthesiologists (ASA) physical status classification system score, modified Charlson Comorbidity Index (mCCI), Elixhauser Comorbidity Measure (ECM), and 5-Factor Modified Frailty Index (mFI-5) were calculated for each patient. Logistic regression models predicting 30-day mortality, discharge disposition, LOS greater than 1 day, and 30-day major and minor complications were fit for each index.

RESULTS

The ASA classification (C-statistic = 0.773 for THA and TKA) and mCCI (THA: c-statistic = 0.781; TKA: C-statistic = 0.771) were good models for predicting 30-day mortality. However, ASA and mCCI were not predictive of major and minor complications, discharge disposition, or LOS. The ECM and mFI-5 did not reliably predict any outcomes of interest.

CONCLUSION

ASA and mCCI are good models for predicting 30-day mortality after THA and TKA. However, similar to ECM and mFI-5, these generic comorbidity risk-assessment tools do not adequately predict 30-day postoperative outcomes or in-hospital metrics. This highlights the need for an updated, data-driven approach for standardized comorbidity reporting and risk assessment in arthroplasty.

A novel predictive model of hospital stay for Total Knee Arthroplasty patients

Objective

This study aimed to explore the main risk factors affecting Total Knee Arthroplasty (TKA) patients and develop a predictive nomogram of hospital stay.

Methods

In total, 2,622 patients undergoing TKA in Singapore were included in this retrospective cohort study. Hospital extension was defined based on the 75% quartile (Q3) of hospital stay. We randomly divided all patients into two groups using a 7:3 ratio of training and validation groups. We performed univariate analyses of the training group, in which variables with P-values < 0.05 were included and then subjected to multivariate analysis. The multivariable logistic regression analysis was applied to build a predicting nomogram, using variable P-values < 0.01. To evaluate the prediction ability of the model, we calculated the C-index. The ROC, Calibration, and DCA curves were drawn to assess the model. Finally, we verified the accuracy of the model using the validation group and by also using the C-index. The ROC curve, Calibration curve, and DCA curve were then applied to evaluate the model in the validation group.

Results

The final study included 2,266 patients. The 75% quartile (Q3) of hospital stay was six days. In total, 457 (20.17%) patients had hospital extensions. There were 1,588 patients in the training group and 678 patients in the validation group. Age, Hb, D.M., Operation Duration, Procedure Description, Day of Operation, Repeat Operation, and Blood Transfusion were used to build the prediction model. The C-index was 0.680 (95% CI: 0.734-0.626) in the training group and 0.710 (95% CI: 0.742-0.678) for the validation set. The calibration curve and DCA indicated that the hospital stay extension model showed good performance in the training and validation groups.

Conclusion

To identify patients' risk factors early, medical teams need to plan a patient's rehabilitation path as a whole. Its advantages lie in better resource allocation, maximizing medical resources, improving the functional recovery of patients, and reducing the overall cost of hospital stay and surgery, and will help clinicians in the future.

Do older patients fare worse following unilateral or single stage bilateral total knee arthroplasty?

INTRODUCTION

The safety and benefits of single stage bilateral total knee arthroplasty (SSBTKA) among older patients as compared to unilateral TKA remains controversial. This study aimed to evaluate the influence of age and comorbidities on complications and early outcomes for unilateral and BTKA in patients over and under 70 years of age.

MATERIALS AND METHODS

This prospective study compared postoperative complications and early patient-reported outcomes at 6 weeks of 142 unilateral TKA patients (N = 75, ≤ 70; N = 67, > 70) and 89 SSBTKA patients (N = 48, ≤ 70; N = 41, > 70). Patients completed the KOOS JR and PROMIS Global Mental (GMH) and Global Physical Health (GPH) surveys. Knee Society Scores for Knee (KSS-K) and Function (KSS-F) were completed in the clinic. Parametric tests were performed for comparisons of unilateral and BTKA outcomes and complications for patients over and under 70.

RESULTS

While patient demographics were similar, patients > 70 had more comorbidities than patients ≤ 70 (p < 0.004). There were no significant differences in postoperative complications or readmissions between age groups or procedures. Unilateral TKA patients > 70 had significantly lower pre- (p < 0.001) and post-operative (p = 0.011) KSS-F scores compared to those ≤ 70. SSBTKA patients > 70 had significantly higher preoperative GMH (p = 0.029), postoperative KSS-K (p = 0.027), KOOS JR scores (p = 0.039) and satisfaction (p = 0.048) compared to those ≤ 70.

CONCLUSION

Age did not influence the risk of early postoperative complications. Additionally, the greater improvements in KOOS JR and higher patient satisfaction for SSBTKA patients > 70 suggests that SSBTKA may meet elderly patient expectations and should not necessarily be discouraged due to safety concerns.

Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies

STUDY DESIGN

Literature review.

OBJECTIVE

The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes.

SUMMARY OF BACKGROUND DATA

There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure.

METHODS

A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed.

RESULTS

Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures.

CONCLUSION

By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

Development and validation of a nomogram to predict complications in patients undergoing simultaneous bilateral total knee arthroplasty: A retrospective study from two centers

Purpose

Complications were significantly increased 30 days after Simultaneous bilateral total knee arthroplasty (SBTKA). In this study, an individualized nomogram was established and validated to predict the complications within 30 days after SBTKA.

Methods

The general data of 861 patients (training set) who received SBTKA in The Affiliated Hospital of Qingdao University between January 1, 2012 and March 31, 2017 were retrospectively analyzed. All patients were divided into complication group (n = 96) and non-complication group (n = 765) according to the incidence of complications within 30 years after SBTKA. Independent risk factors for postoperative SBTKA complications were identified and screened by binary logistic regression analyses, and then a nomogram prediction model was constructed using R software. The area under curve (AUC), calibration curve, and decision curve analysis (DCA) were selected to evaluate the line-chart. Meanwhile, 396 patients receiving SBTKA in the Third Hospital of Hebei Medical University who met the inclusion and exclusion criteria (test set) were selected to verify the nomogram.

Results

Five independent predictors were identified by binary logistic regression analyses and a nomogram was established. The AUC of this nomogram curve is 0.851 (95% CI: 0.819–0.883) and 0.818 (95% CI: 0.735–0.900) in the training and testing sets, respectively. In the training set and test set, calibration curves show that nomogram prediction results are in good agreement with actual observation results, and DCA shows that nomogram prediction results have good clinical application value.

Conclusion

Older age, lower preoperative hemoglobin level, higher preoperative blood urea nitrogen (BUN) level, longer operation time, ASA grade ≥ III are independent predictors of SBTKA complications within 30 days after surgery. A nomogram containing these five predictors can accurately predict the risk of complications within 30 days after SBTKA.

Projections for primary hip and knee replacement surgery up to the year 2060: an analysis based on data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

INTRODUCTION

We estimated the number of primary total hip and knee replacements (THR and TKR) that will need to be performed up to the year 2060.

METHODS

We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the volume of primary THRs (n=94,936) and TKRs (n=100,547) performed in 2018. We projected future numbers of THR and TKR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060.

RESULTS

By 2060, THR and TKR volume would increase from 2018 levels by an estimated 37.7% (n=130,766) and 36.6% (n=137,341), respectively. For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70-79 years (44.6% males, 41.2% females); 80-89 years (112.4% males, 85.6% females); 90 years and older (348.0% males, 198.2% females).

CONCLUSION

By 2060 demand for hip and knee joint replacement is estimated to increase by almost 40%. Demand will be greatest in older patients (70+ years), which will have significant implications for the health service requiring forward planning given that morbidity and resource use is higher in this population. These issues, coupled with two waves of COVID-19, will impact the ability of health services to deliver timely joint replacement to many patients for a number of years, requiring urgent planning.

Decreased Implant Survival is Associated With Younger Patients Undergoing Total Knee Arthroplasty

Background: Younger patients are undergoing total knee arthroplasty (TKA) at increasing rates and may face multiple revisions during their lifetimes due to mechanical complications or infections. Questions/Purposes: We sought to compare the early complication rates and revision-free implant-survival rates across age groups of patients undergoing TKA, with particular focus on implant survival in younger patients. Methods: We conducted a retrospective analysis of data taken from a national insurance database on patients who underwent primary TKA from 2007 to 2015. Kaplan-Meier curve survival analysis and log rank test were performed to evaluate revision rates in 7 age groups (younger than 40, 40-49, 50-59, 60-69, 70-79, 80-89, and 90 or more years of age). Complication rates were compared to rates in the age 60 to 79 years age groups using multiple logistic regression, controlling for baseline demographics and comorbidities. Results: There were 114,698 patients included in the analysis. Patients in the younger than 40 years, 40 to 49 years, and 50 to 59 years age groups had increased rates of early mechanical complications; 90-day readmission rates were significantly higher in those age groups as well. Revision-free implant survival at 5 years was significantly worse in patients younger than 60 years of age, particularly those less than 40 years, who had a 77% revision-free implant-survival rate at 5 years. Conclusions: Younger patients had a higher risk of early revision after TKA, as well as an increased rate of mechanical complications and readmissions at 90 days. These outcomes suggest more study is needed to better understand these discrepancies and to better guide preoperative counseling for young patients considering TKA.

Nomogram to predict postoperative complications in elderly with total hip replacement

BACKGROUND

By analyzing the risk factors of postoperative complications in elderly patients with hip replacement, We aimed to develop a nomogram model based on preoperative and intraoperative variables and verified the sensitivity and specificity for risk stratification of postoperative complications in elderly with total hip replacement patients.

AIM

To develop a nomogram model for risk stratification of postoperative complications in elderly with total hip replacement patients.

METHODS

A total of 414 elderly patients who underwent surgical treatment for total hip replacement hospitalized at the Affiliated Hospital of Guangdong Medical University from March 1, 2017 to August 31, 2019 were included into this study. Univariate and multivariate logistic regression were conducted to identify independent risk factors of postoperative complication in the 414 patients. A nomogram was developed by R software and validated to predict the risk of postoperative complications.

RESULTS

Multivariate logistic regression analysis revealed that age (OR = 1.05, 95%CI: 1.00-1.09), renal failure (OR = 0.90, 95%CI: 0.83-0.97), Type 2 diabetes (OR = 1.05, 95%CI: 1.00-1.09), albumin (ALB) (OR = 0.91, 95%CI: 0.83-0.99) were independent risk factors of postoperative complication in elderly patients with hip replacement (P < 0.05). For validation of the nomogram, receive operating characteristic curve revealed that the model predicting postoperative complication in elderly patients with hip replacement was the area under the curve of 0.8254 (95%CI: 0.78-0.87), the slope of the calibration plot was close to 1 and the model passed Hosmer-Lemeshow goodness of fit test (χ² = 10.16, P = 0.4264), calibration in R E_max = 0.176, E_avg = 0.027, which all demonstrated that the model was of good accuracy.

CONCLUSION

The nomogram predicting postoperative complications in patients with total hip replacement constructed based on age, type 2 diabetes, renal failure and ALB is of good discrimination and accuracy, which was of clinical significance.

Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299-7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.

Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients

INTRODUCTION

Studies investigating complications between octogenarians and non-octogenarians undergoing primary total knee arthroplasty (TKA) are limited. Therefore, we investigated whether octogenarians are at greater odds of: (1) in-hospital lengths of stay (LOS) (2) readmission rates, (3) medical complications, and (4) hardware complications compared to non-octogenarians following TKA.

METHODS

A retrospective query of the PearlDiver database isolated 1,775,460 patients who underwent primary TKA from 2005 to 2014. Patients aged 80 and above represented the study cohort (n = 295,908) and patients 65 to 79 represented the control cohort (n = 1,479,552). Study group patients were matched to controls in a 1:5 ratio according to gender and medical comorbidities. Pearson's Chi Square and logistic regression were used to analyze the primary outcomes of the study which included 90-day medical complications, 90-day readmission rates, 2-year implant-related complications, and in-hospital LOS. A p-value less than 0.001 was statistically significant.

RESULTS

Octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates (10.59 vs. 9.35%; OR: 1.15, p < 0.0001) and significantly longer in-hospital LOS (3.69 days ± 1.95 vs. 3.23 days ± 1.83, p < 0.0001) compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication (1.26 vs. 1.26%; OR: 0.99, p = 0.99) and lower incidence and odds (1.67 vs. 1.93%; OR: 0.86, p < 0.001) of implant-related complications compared to controls.

CONCLUSION

Octogenarians undergoing primary TKA have similar odds of medical related complications and lower odds of implant-related complications compared to non-octogenarian patients, whereas readmission rates and in-hospital LOS are greater.

Prediction of 90-Day Local Complications in Patients After Total Knee Arthroplasty: A Nomogram With External Validation

Background:

Local complications after total knee arthroplasty (TKA) significantly affect the patient’s prognosis. Nomograms can be a useful tool for predicting such complications.

Purpose:

To compare the preoperative and intraoperative factors of patients who underwent TKA with and without complications and to construct and validate a nomogram based on selective predictors of local complications within 90 days postoperatively.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The nomogram was developed in a primary cohort that consisted of 410 patients who underwent primary TKA at the authors’ institution between January 2015 and September 2018. Predictor variables included 4 major local complications that can occur within 90 days: reoperation (including implant revision or removal for any reason and manipulation under anesthesia), infection, bleeding requiring ≥4 unit transfusion of red blood cells within 72 hours of surgery, and peripheral nerve injury. The authors used least absolute shrinkage and selection operator (LASSO) regression analysis for data dimension reduction and feature selection. Multivariable logistic regression analysis was used to develop the nomogram. Performance of the nomogram was assessed using C-index, calibration plot, area under the receiver operating characteristic curve (AUC), and decision curve analysis (DCA). The model was subjected to bootstrap validation and external validation using a prospective cohort of 249 patients.

Results:

Four significantly prognostic factors were incorporated into the nomogram: age-adjusted Charlson Comorbidity Index, American Society of Anesthesiologists score, tourniquet time, and estimated intraoperative blood loss. The model displayed good discrimination, with a C-index of 0.819 and an AUC of 0.819. The calibration curves showed optimal agreement between nomogram prediction and actual observation. A high C-index value of 0.801 could still be reached in bootstrap validation. Application of the nomogram in the validation cohort showed good discrimination (C-index, 0.731) and good calibration. DCA demonstrated that the nomogram was clinically useful.

Conclusion:

The authors developed and validated a novel nomogram that can provide individual prediction of local complications within 90 days for patients after TKA. This practical tool may be conveniently used to estimate individual risk and help clinicians take measures to minimize or prevent the incidence of complications.

Construction and Comparison of Predictive Models for Length of Stay after Total Knee Arthroplasty: Regression Model and Machine Learning Analysis Based on 1,826 Cases in a Single Singapore Center

The purpose of this study was to develop a predictive model for length of stay (LOS) after total knee arthroplasty (TKA). Between 2013 and 2014, 1,826 patients who underwent TKA from a single Singapore center were enrolled in the study after qualification. Demographics of patients with normal and prolonged LOS were analyzed. The risk variables that could affect LOS were identified by univariate analysis. Predictive models for LOS after TKA by logistic regression or machine learning were constructed and compared. The univariate analysis showed that age, American Society of Anesthesiologist level, diabetes, ischemic heart disease, congestive heart failure, general anesthesia, and operation duration were risk factors that could affect LOS (p < 0.05). Comparing with logistic regression models, the machine learning model with all variables was the best model to predict LOS after TKA, of whose area of operator characteristic curve was 0.738. Machine learning algorithms improved the predictive performance of LOS prediction models for TKA patients.

Risk factors of postoperative complications following total knee arthroplasty in Korea: A nationwide retrospective cohort study

BACKGROUND

The number of patients undergoing total knee arthroplasty (TKA) is gradually increasing and there is also increase in postoperative complications. The patient's demographic, socio-economic factors, hospital and clinical factors are all factors that can influence postoperative complications. The purpose of this study was to determine the risk factors associated with complications following TKA in a large national cohort.

METHODS

Among patients diagnosed with primary knee arthrosis, a total of 560,954 patients older than 50 years who underwent TKA from January 1, 2005 to December 31, 2018 were included in the study. The risk of postoperative complications (surgical site infection, sepsis, cardiovascular complications, respiratory complications, pulmonary embolism, stroke, acute renal failure, periprosthetic joint infection, and periprosthetic fracture) were assessed with eight independent variables: gender, age, place of residence, household income, hospital bed size, procedure type (unilateral or bilateral, primary or revision TKA), length of stay (LOS), use of transfusion. Multivariable Cox Proportional Hazard model analysis was used. The significant predictors for complications (P < .05) were as follows.

RESULTS

Surgical site infection: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Sepsis: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Cardiovascular complications: male, age, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Respiratory complications: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Pulmonary embolism: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Stroke: male, age, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Acute renal failure: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic joint infection: male, household income, procedure type (bilateral, revision), LOS (≥35 days), transfusion. Periprosthetic fracture: male, procedure type (bilateral, revision), LOS (≥35 days), transfusion.

CONCLUSION

In summary, male, procedure type (bilateral, revision), LOS (≥35 days), and use of transfusion were shown to be risk factors of postoperative complications following TKA.

Predictors of 90-Day All-Cause Morbidity, Mortality and Poor Functional Outcome Scores Following Elective Total Knee Arthroplasty in a High-Volume Setting: A Prospective Cohort Study

BACKGROUND

The primary objective was to ascertain the predictors of 90-day all-cause morbidity, mortality and poor functional outcome scores following primary total knee arthroplasty (TKA).

MATERIAL AND METHOD

The study population comprised 3645 patients who underwent elective primary unilateral TKA at our institution. Demographic variables, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) grade and the Deyo-Charlson comorbidity scores were ascertained. The Functional outcomes, perioperative complications, mortality and readmission rates were monitored prospectively for 90 days and analysed. Patients were assessed twice: at baseline and at 90 days postoperatively. Odds ratio and the corresponding 95% confidence intervals were calculated to quantify the risk. A p < 0.05 for two-tailed tests were considered significant.

RESULT

The 90-day mortality rate was 0.08% (all males) and 3.95% of the patients experienced one or the other complications. The majority of patients reported excellent-to-poor scores at 90-day follow-up VAS (8.85 ± 1.02 vs. 2.65 ± 1.15; p < 0.0001) and KSS scores (42.96 ± 5.90 vs. 80.52 ± 4.15; p < 0.0001). The early readmission rate was 0.96%. Infection was being the primary reason. Age > 70 years; Deyo-Charlson co-morbidity score ≥ 4, ASA grade-III, Diabetes Mellitus, BMI > 35, Cardiac Issues and Male gender were significant predictors of early morbidity and mortality. Female, Deyo-Charlson comorbidity score ≥ 4, ASA grade-III, BMI > 35, Age > 75 years and poor preoperative scores were significantly associated with poor functional outcome.

CONCLUSION

The present study explicates the relative importance of predictors on morbidity, mortality and functional outcome. Efforts to minimize morbidity and mortality should concentrate more on elderly male patients, and those with high Deyo-Charlson comorbidity score, BMI and ASA grade.

How Long Do Octogenarians Benefit From Knee Arthroplasty?

Introduction

Elderly patients are more prone to surgical risk regardless of the procedure. The overall mortality rate is expected to be high in this population. The aim of this study was to evaluate the survival rates of octogenarians who underwent knee arthroplasty procedures.

Methods

Sixty-two knee arthroplasties were performed on 52 patients who were >80 years of age at the time of the operation between November 1996 and May 2014. The preoperative American Society of Anesthesiologists (ASA) classes were available for 45 procedures. The database of the Civil Registry Service was used to assess whether the patients were alive at the time of the study. If they were deceased, their dates of death were recorded. The five-, 10-, and 15-year survival rates of patients were determined.

Results

Thirty patients (57.69%) were alive and 22 (42.31%) were deceased at the time of analysis. Based on the 62 procedures, the mean age of the patients at the time of the operation was 82.56 ± 2.18 years. The mean time span between the operation and death of patients who passed away was 6.4 ± 4.66 years. The mean age of the patients who were alive at the time of the study was 86.63 ± 3.60 years. The mean time that had passed since the operation was 4.41 ± 2.9 years for living patients. Only one patient died during the first 90 days postoperatively. The one-year mortality rate was 4.84% (three patients). A Kaplan-Meier survival analysis revealed that the mean survival time of the patients was 6.4 years, and the median survival time was 5.6 years. The five-year survival rate was 59%, the 10-year rate was 19%, and the 15-year rate was 7%.

Conclusion

Octogenarians benefitted from knee replacement longer than expected. Early mortality risks can be avoided with proper patient selection.

Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population

BACKGROUND

Improved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1.

METHODS

A retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05).

RESULTS

Of those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]).

CONCLUSION

Most patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.

Predictors for readmission following primary total hip and total knee arthroplasty

BACKGROUND

Readmission following total joint arthroplasty has become a closely watched metric for many hospitals in the United States due to financial penalties imposed by Centers for Medicare and Medicaid Services. The purpose of this study was to identify both preoperative and postoperative reasons for readmission within 30 days following primary total hip and total knee arthroplasty (TKA).

METHODS

Retrospective data were collected for patients who underwent elective primary total hip arthroplasty (THA; CPT code 27130) and TKA (27447) from 2008 to 2013 at our institution. The sample was separated into readmitted and nonreadmitted cohorts. Demography, comorbidities, Charlson comorbidity index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis.

RESULTS

There were 42 (3.4%) and 28 (2.2%) readmissions within 30 days for THA and TKA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among THA and TKA patients, including body mass index, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA.

CONCLUSION

Patient comorbidities and preoperative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered and we recommend the use of CCI and METs in risk adjustment models that use 30-day readmission as a marker for quality of patient care.

LEVEL OF EVIDENCE

Level III/Retrospective cohort study.

Day-case total hip arthroplasty: a literature review and development of a hospital pathway

Aims

We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

Methods

We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

Results

Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit.

Conclusion

Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA.

Cite this article: Bone Jt Open 2021;2(2):93–102.

Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties

BACKGROUND

Establishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA).

METHODS

This was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations.

RESULTS

In a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m² were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m² were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA.

CONCLUSION

This study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.

Total knee arthroplasty improves the quality-adjusted life years in patients who exceeded their estimated life expectancy

Purpose

Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis though its risk-benefit ratio in elderly patients remains debated. This study aimed to evaluate the functional outcome, rates of complication and mortality, and quality-adjusted life years (QALY) in patients who exceeded their estimated life expectancy.

Methods

Ninety-seven TKA implanted in 86 patients who exceeded their estimated life expectancy at the time of TKA were prospectively included in our institutional joint registry and retrospectively analyzed. At latest follow-up, the functional outcome with the Knee Society Score (KSS), rates of complication and mortality, and QALY with utility value of EuroQol-5D score were evaluated.

Results

At a mean follow-up of three ± one years, the pre- to post-operative KSS improved significantly (p < 0.01). The rates of surgical and major medical complications related to TKA were 3% and 10%, respectively. The re-operation rate with readmission was 3% while no TKA was revised. The 30-day and one year mortality was 1% and 3%, respectively. The pre- to one year post-operative QALY improved significantly (p < 0.01). The cumulative QALY five years after TKA was four years. Assuming that these patients did not undergo TKA, their cumulative QALY at five years would have been only two years.

Conclusion

TKA is an effective procedure for the treatment of end-stage osteoarthritis in patients who exceeded their estimated life expectancy. TKA provided significant improvement in function and quality of life without adversely affecting overall morbidity and mortality. Therefore, TKA should not be contra-indicated in elderly patients based on their advanced age alone.

Predictive models for identifying risk of readmission after index hospitalization for hip arthroplasty: A systematic review

BACKGROUND

An aging United States population profoundly impacts healthcare from both a medical and financial standpoint, especially with an increase in related procedures such as Total Hip Arthroplasty (THA). The Hospital Readmission Reduction Program and Comprehensive Care for Joint Replacement Program incentivize hospitals to decrease post-operative readmissions by correlating reimbursements with smoother care transitions, thereby decreasing hospital burden and improving quantifiable patient outcomes. Many studies have proposed predictive models built upon risk factors for predicting 30-day THA readmissions.

QUESTIONS

(1) Are there validated statistical models that predict 30-day readmissions for THA patients when appraised with a standards-based, reliable assessment tool?. (2) Which evidence-based factors are significant and have support across models for predicting risk of 30-day readmissions post-THA?

METHODS

Five major electronic databases were searched to identify studies that examined correlations between post-THA readmission and risk factors using multivariate models. We rigorously applied the PRISMA methodology and TRIPOD criteria for assessment of the prognostic studies.

RESULTS

We found 26 studies that offered predictive models, of which two presented models tested with validation cohorts. In addition to the many factors grouped into demographic, administrative, and clinical categories, bleeding disorder, higher ASA status, discharge disposition, and functional status appeared to have broad and significant support across the studies.

CONCLUSIONS

Reporting of recent predictive models establishing risk factors for 30-day THA readmissions against the current standard could be improved. Aside from building better performing models, more work is needed to follow the thorough process of undergoing calibration, external validation, and integration with existing EHR systems for pursuing their use in clinical settings. There are several risk factors that are significant in multiple models; these factors should be closely examined clinically and leveraged in future risk modeling efforts.

The Impact of Malnutrition on 30-Day Postoperative Complications following Surgical Fixation of Distal Radius Fractures

Introduction  Distal radius fractures (DRFs) are increasingly managed surgically among fragility fractures due to prolonged life expectancy and surgical advancements. Yet, malnutrition can impact postoperative outcomes and complications. We sought to determine the impact of malnutrition on open reduction and internal fixation (ORIF) of DRFs during the perioperative and 30-day postoperative periods. Materials and Methods  Using the National Surgical Quality Improvement Program database, all patients who underwent ORIF of a DRF between January 1, 2008, and December 31, 2016, were identified and stratified by preoperative serum albumin levels: normal (≥3.5 g/dL; n = 2,546) or hypoalbuminemia (<3.5 g/dL; n = 439). Demographical and perioperative data were compared. Operative complications were stratified into major and minor complications, and data were analyzed using descriptive statistics and multivariate regression models. Results  Compared with patients with normal levels, a higher proportion of hypoalbuminemia patients had ASA scores > 3 (9.1 vs. 2%) and a longer mean length of stay (3.16 vs. 0.83 days). Hypoalbuminemia patients also had 625% greater odds for developing major complications during the 30-day postoperative period (odds ratio = 7.25; 95% confidence interval: 1.91-27.49). Conclusion  Malnutrition significantly affected outcomes and complications of distal radius ORIF. This study highlights the importance of prevention and treatment of malnutrition in the setting of fragility fractures.

Risk Factors for Readmission After Knee Arthroplasty Based on Predictive Models: A Systematic Review

BACKGROUND

An increase in the aging yet active US population will continue to make total knee arthroplasty (TKA) procedures routine in the coming decades. For such joint procedures, the Centers for Medicare and Medicaid Services introduced programs such as the Comprehensive Care for Joint Replacement to emphasize accountable and efficient transitions of care. Accordingly, many studies have proposed models using risk factors for predicting readmissions after the procedure. We performed a systematic review of TKA literature to identify such models and risk factors therein using a reliable appraisal tool for their quality assessment.

METHODS

Five databases were searched to identify studies that examined correlations between post-TKA readmission and risk factors using multivariate models. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology and Transparent Reporting of a multivariate prediction model for Individual Prognosis Or Diagnosis criteria established for quality assessment of prognostic studies.

RESULTS

Of 29 models in the final selection, 6 models reported performance using a C-statistic, ranging from 0.51 to 0.76, and 2 studies used a validation cohort for assessment. The average 30-day and 90-day readmission rates across the studies were 5.33% and 7.12%, respectively. Three new significant risk factors were discovered.

CONCLUSIONS

Current models for TKA readmissions lack in performance measurement and reporting when assessed with established criteria. In addition to using new techniques for better performance, work is needed to build models that follow the systematic process of calibration, external validation, and reporting for pursuing their deployment in clinical settings.

Malnutrition increases the 30-day complication and re-operation rates in hip fracture patients treated with total hip arthroplasty

INTRODUCTION

This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates.

METHODS

The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates.

RESULTS

Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43-2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31-3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42-2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20-3.23).

CONCLUSIONS

The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk.

Does the Timing of the Second Surgery of a Staged Bilateral Total Joint Arthroplasty Affect the Rate of Hospital Adverse Events and Perioperative Outcomes?

BACKGROUND

The optimal timing of the second surgery in primary staged bilateral total hip/knee arthroplasty remains uncertain. Perioperative hospital adverse events represent a significant issue, even "minor events" lead to substantial costs in workup tests, interconsultations, and/or increased hospital length-of-stay (LOS). Therefore, we sought to ascertain whether the timing of the second arthroplasty affects perioperative outcomes and/or rates of adverse events.

METHODS

We retrospectively reviewed a consecutive series of 670 primary staged bilateral total hip/knee arthroplasty performed by 2 surgeons (2010-2016) at a single institution. The days between both arthroplasties were calculated for each pair of hips or knees. We evaluated demographics and LOS, discharge disposition, adverse events (ie, nausea, pulmonary embolism), and transfusion rates. The second arthroplasties (n = 335) were set apart in 2 groups based on the time they were done with respect to their corresponding contralateral first arthroplasty using 3 different thresholds: (1) ≤90 vs >90 days, (2) ≤180 vs >180 days, and (3) ≤365 vs >365 days.

RESULTS

No significant differences in outcome comparisons were observed using either 90 or 180 days thresholds. However, using the 365 days thresholds, the mean LOS (2.21 vs 1.92 days, P = .015), adverse event (26% vs 15.3%, P = .021), total transfusion (7.4% vs 1.5%, P = .020), and allogeneic transfusion (6.9% vs 1.5%, P = .033) rates were significantly higher in second arthroplasties performed at or less than 1 year apart from the first, respectively.

CONCLUSION

Staging the second arthroplasty more than a year apart from the first one seems to offer better LOS and rates of hospital adverse events, transfusions. However, unless patients are willing to wait a year between surgeries, our data also suggest no increased risk in regards to adverse events when proceeding before or after 90/180 days.

LEVEL OF EVIDENCE

Level III.

Hospital Adverse Events and Perioperative Outcomes in Bilateral Direct Anterior Approach Total Hip Arthroplasty

BACKGROUND

Perioperative hospital adverse events represent a significant outcome that is often overlooked. Even "minor events" such as fever or tachycardia may lead to significant costs due to workup tests, interconsultations, and/or increased length of stay (LOS). The optimal timing of bilateral direct anterior approach total hip arthroplasty (DAA-THA) remains unsettled. Consequently, we wanted to compare hospital LOS, discharge disposition, hospital adverse events (major and minor), and transfusion rates between simultaneous and staged bilateral DAA-THA.

METHODS

A retrospective chart review was conducted on a consecutive series of 347 primary bilateral DAA-THAs (204 patients) performed by 2 surgeons in a single institution (2010-2016). The hips finally included were categorized as simultaneous (Sim-n = 61), staged 1 (Stg1-n = 143), or staged 2 (Stg2-n = 143). We also compared simultaneous with staged surgeries performed ≤1 and >1 year apart. Baseline demographics, LOS, discharge disposition, hospital adverse events, and transfusions were assessed.

RESULTS

The simultaneous group had significantly younger patients and a higher proportion of males when compared with the staged groups and showed significant longer LOS [2.61 (Sim) vs 2.06 (Stg1) vs 1.63 (Stg2) days, P < .001], lower proportion of home discharge [77% (Sim) vs 91.6% (Stg1) vs 96.5% (Stg2), P < .001], as well as higher (overall) rate of adverse events [31.1% (Sim) vs 28.7% (Stg1) vs 14.0% (Stg2), P = .003] and transfusions [45.9% (Sim) vs 6.3% (Stg1) vs 7.0% (Stg2), P < .001]. However, most transfusions were autologous [37.7% (Sim) vs 3.5% (Stg1) vs 0% (Stg2), P < .001].

CONCLUSION

Our data show that bilateral DAA-THAs performed in a staged fashion, rather than simultaneously, have a shorter hospital LOS and decreased rates of adverse events and overall transfusions. Notwithstanding, simultaneous surgery should still be considered an option in selected patients.

LEVEL OF EVIDENCE

Level III.

A simple nomogram for predicting early complications in patients after primary knee arthroplasty

BACKGROUND

This study sought to construct a nomogram for patients based on preoperative and intraoperative variables to individually predict the likelihood of complications within 30 days after primary knee arthroplasty.

METHODS

Data were obtained from the medical record of patients who underwent primary knee arthroplasty at our institution from 2015 to 2018. Preoperative and intraoperative factors were collected critically. Predictor variables include 15 common complications occurring within 30 days. The predictive model was developed using multivariable logistic regression and least absolute shrinkage and selection operator regression. Clinical usefulness and calibration of the predicting model were assessed using C-index, calibration plot, receiver operating curve, and decision curve analysis. Internal validation was assessed using the bootstrapping validation.

RESULTS

The prediction nomogram identified six variables associated with complications, including hemoglobin, tourniquet time, operative time, estimated intraoperative blood loss, American Society of Anesthesiologists Classification (ASA class) and type of anesthesia. The model displayed good discrimination with a C-index of 0.822 (95% confidence interval: 0.760-0.884), an area under the curve of 0.822 and good calibration. High C-index value of 0.810 could still be reached in the interval validation. Decision curve analysis showed that the nomogram was clinically useful when intervention was decided at the complications possibility threshold in the three percent to 100% range.

CONCLUSION

We constructed and validated a nomogram for predicting the probability of postoperative complications within 30 days after primary knee arthroplasty. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions.

Risk factors for readmission within thirty days following revision total hip arthroplasty

BACKGROUND

The number of total hip arthroplasties (THA) being performed has been steadily increasing for decades. With increased primary THA surgical volume, revision THA numbers are also increasing at a steady pace. With the aging, increasingly comorbid patient populations and newly imposed financial penalties for hospitals with high readmission rates, refining understanding of factors influencing readmission following THA is a research priority. We hypothesize that numerous preoperative medical comorbidities and postoperative medical complications will emerge as significant positive risk factors for 30-day readmission.

METHODS

ACS-NSQIP database identified patients who underwent revision THA from 2005 to 2015. The primary outcome assessed was hospital readmission within 30 days. Patient demographics, preoperative comorbidities, laboratory studies, operative characteristics, and postsurgical complications were compared between readmitted and non-readmitted patients. Logistic regression identified significant independent risk factors for 30-day readmission among these variables.

RESULTS

10,032 patients underwent revision THA in the ACS-NSQIP from 2005 to 2015; 855 (8.5%) were readmitted within 30-days. Increasing age, the presence of preoperative comorbidities, high ASA class, and increased operative time were significant positively associated independent risk factors for 30-day readmission. Several postoperative medical and surgical complications such as myocardial infarction, stroke, pneumonia, and sepsis demonstrated significant positive associations with readmission.

CONCLUSION

Identifying and understanding risk factors associated with readmission allows for the implementation of evidence-based interventions aimed at minimizing risk and reducing 30-day readmission rates following revision THA.

Readmission Rates for One Versus Two-Midnight Length of Stay for Primary Total Knee Arthroplasty: Analysis of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Database

BACKGROUND

The length of stay (LOS) in the hospital for total knee arthroplasty (TKA) has been declining over recent decades. The purpose of this study was to determine if patients with an LOS for TKA that includes only 1 midnight have an increased odds of 90-day readmission compared with those with a 2-midnight LOS. We also sought to identify any predictors of 90-day hospital readmission among those readmitted during our period of analysis.

METHODS

A retrospective review of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was performed to identify patients with a 1-midnight or 2-midnight LOS for TKA during a 5-year period. The primary end point of this study was inpatient readmission within the 90-day postoperative period. A multiple logistic regression model and propensity score matching were used to compare the odds of 90-day readmission between 1-midnight and 2-midnight LOS. The secondary end points of this study were 90-day complications.

RESULTS

There were 96,250 TKA procedures identified in the database, and 46,709 met our inclusion criteria for LOS. No difference in 90-day-readmission odds between patients with a 1-midnight LOS and those with a 2-midnight LOS for primary TKA was identified. Male sex, single marital status, age of ≥80 years, type-I diabetes, previous smoking, narcotic use prior to surgery, and a higher American Society of Anesthesiologists (ASA) scores increased the odds of 90-day readmission. Patients in the age group of ≥50 to <65 years, those with a higher preoperative hemoglobin level, and those with a positive social history of alcohol use were found to have decreased odds of readmission.

CONCLUSIONS

We found no association between the LOS for primary TKA (1 midnight compared with 2 midnights) and the 90-day readmission risk.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors.

METHODS

Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms "total knee arthroplasty" and "length of stay". Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (RevMan) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014).

RESULTS

A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference [MD] = 0.81; 95% confidence interval [CI] = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98).

CONCLUSION

This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative "fast-track" programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications.

LEVEL OF EVIDENCE

IV, systematic review, and meta-analysis of level III and IV evidence.

Perioperative morbidity in total knee arthroplasty

Introduction

As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors.

Methods

It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications.

Results

Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation.

Conclusion

This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.

Pharmacotherapy options and drug development in managing periprosthetic joint infections in the elderly

INTRODUCTION

Prosthetic joint infections are an increasingly important problem among patients undergoing arthroplasty procedures, and are associated with significant morbidity, reduced quality of life, substantial healthcare costs, and even mortality. Arthroplasties are performed with increasing frequency in elderly patients, who present specific problems.

AREAS COVERED

Surgical therapy is clearly influenced by the clinical status of the patient, which in some case can contraindicate surgery. Antibiotic selection is also affected by comorbidities and underlying diseases, which in some cases reduce therapeutic options. The authors review this together with the changes in pharmacokinetics and pharmacodynamics in the elderly population and the prospects for future research on prevention and treatment.

EXPERT OPINION

The management of PJI in the elderly makes multidisciplinary teams even more mandatory than in other patients, because the complexity of these patients. A frequent scenario is that in which surgery is contraindicated with long-term suppressive treatment as the only available option. Treating physicians must consider the presence of multiple comorbidities, interactions with other treatments and secondary effects when choosing antibiotic treatment. An in-depth knowledge of the alterations in pharmacokinetics and pharmacodynamics in elderly patients is key for a proper treatment selection.

Effect of Physical Parameters on Outcomes of Total Knee Arthroplasty

BACKGROUND

Increasing body mass index (BMI) has been shown to correlate with increased rates of complications after total knee arthroplasty. To our knowledge, body surface area, body mass, and height have not been investigated in this manner. BMI and body surface area are affected differently by changes in height, and they are affected similarly by changes in weight. The purpose of this study was to quantify revision for any reason, mechanical failure, aseptic loosening, polyethylene wear, reoperation, and any infection after total knee arthroplasty using BMI, body surface area, body mass, and height as continuous variables.

METHODS

Prospectively collected data from a single institution's total joint registry were used to analyze 22,243 consecutive knees, in 16,106 patients, treated with a primary total knee arthroplasty from 1985 to 2012. The Kaplan-Meier survival method was used to evaluate revision and other common complications, with outcomes assessed using Cox regression analysis. Smoothing spline parameterization was used on physical parameters in these models.

RESULTS

Increasing BMI, body surface area, body mass, and height were associated with an increased risk of any revision surgical procedure, mechanical failure, and aseptic loosening after total knee arthroplasty. The risk of a revision surgical procedure was directly associated with each 1 standard deviation increase in BMI (hazard ratio [HR], 1.19; p < 0.01), body surface area (HR, 1.37; p < 0.01), body mass (HR, 1.30; p < 0.01), and height (HR, 1.22; p < 0.01). This association was especially demonstrated with revision for mechanical failure (BMI: HR, 1.15; p < 0.01; body surface area: HR, 1.35; p < 0.01; body mass: HR, 1.27; p < 0.01; and height: HR, 1.23; p < 0.01). The risk of failure in the subgroups of mechanical failure including a revision surgical procedure for aseptic loosening or polyethylene wear was also associated with increasing body surface area, body mass, and height. Increasing BMI (HR, 1.22; p < 0.01), body surface area (HR, 2.56; p < 0.01), and body mass (HR, 2.54; p < 0.01) were also associated with increased risk of any infection.

CONCLUSIONS

Increasing BMI, body surface area, body mass, and height were strongly associated with the rates of revision, aseptic loosening, and other common complications following total knee arthroplasty. Body surface area and body mass appear to correlate more strongly with mechanical failure outcomes than BMI or height.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

G, Shah A, Godoy-Santos AL, Naranje S. RISK FACTORS FOR EARLY HOSPITAL READMISSION FOLLOWING TOTAL KNEE ARTHROPLASTY

Objective

To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty.

Methods

Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission.

Results

137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations.

Conclusions

Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study.

Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

BACKGROUND

The Comprehensive Care for Joint Replacement program implemented by the Centers for Medicare and Medicaid Services did not incorporate risk adjustment for lower extremity joint replacement (LEJR). Lack of adjustment places hospitals at financial risk and creates incentives for adverse patient selection.

OBJECTIVE

To identify patient-level risk factors associated with health care utilization and costs of patients undergoing LEJR.

METHODS

A comprehensive search of research databases from January 1, 1990, through January 31, 2016, was conducted. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and SCOPUS and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search identified 2020 studies. Eligible studies focused on primary unilateral and bilateral LEJR. Independent reviewers determined study eligibility and extracted utilization and cost data.

RESULTS

Seventy-nine of 330 studies (24%) were included and were abstracted for analysis. Comorbidities, age, disease severity, and obesity were associated with increased costs. Increased number of comorbidities and age, presence of specific comorbidities, lower socioeconomic status, and female sex had evidence of increased length of stay. We found no significant association between indication for surgery and the likelihood of readmission.

CONCLUSION

Developing a risk adjustment model for LEJR that incorporates clinical variables may serve to reduce the likelihood of adverse patient selection and enhance appropriate reimbursement aligned with procedural complexity.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Knee Arthroplasty

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major global health issue and a leading cause of morbidity and mortality. Patients with COPD are at increased risk of complications following surgery. The purpose of this study is to evaluate the postoperative total knee arthroplasty (TKA) outcomes in these patients in comparison to a non-COPD matching cohort. Specifically, we asked the following questions: (1) "Is COPD associated with adverse perioperative outcomes?" and (2) "Does COPD increase the risk of short-term complications following TKA?"

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 111,168 patients who underwent TKA between 2008 and 2014. A total of 3975 patients with COPD were identified. Both COPD and non-COPD cohorts were compared in terms of the following outcomes: hospital length of stay, discharge disposition, and 30-day postoperative complications.

RESULTS

COPD was a predictor for a prolonged length of stay and a discharge to an extended care facility (P < .001). They were at significantly increased risk of any complication including increased mortality, pneumonia, reintubation, use of a mechanical ventilator for >48 hours, cardiac arrest, progressive renal insufficiency, deep infection, return to operating room, and a readmission within 30 days postoperatively.

CONCLUSION

Patients with COPD are more likely to experience postoperative complications following TKA when compared to non-COPD patients. Pulmonary evaluation and optimization are crucial to minimize adverse events from occurring in this difficult-to-treat population.

One-year mortality and Periprosthetic infection rates after Total knee Arthroplasty in Cancer patients: a population-based cohort study

BACKGROUND

Knowledge on periprosthetic infection and mortality rate following total knee arthroplasty (TKA) is essential for justifying this treatment in patients with cancer; however, relevant data from population-based studies are lacking. Therefore, we examined 1-year periprosthetic infection, mortality, and 5-year relative survival rates in cancer patients who underwent TKA.

METHODS

This is a population-based cohort study based on analysis of the Taiwan National Health Insurance Research Database. We enrolled a total of 2294 cancer patients and 131,849 patients without cancer (control group) who underwent TKA between January 1, 1997, and December 31, 2011. All patients were followed until death, infection, withdrawal from the National Health Insurance, or December 31, 2012.

RESULTS

The periprosthetic knee joint infection rate in cancer patients (1.73%) was not significantly higher than that in the control group (1.87%). However, the 1-year mortality rate was significantly higher (p < 0.05) in the cancer group (4.10%) than in the control group (1.66%). The overall 5-year survival rate was 93.10% as compared with those without cancers.

CONCLUSION

Low periprosthetic knee joint infection rates and high 5-year relative survival rates indicate the feasibility of TKA in cancer patients. However, the surgeon should take into account a higher mortality rate in the first year following TKA.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Hip Arthroplasty

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Furthermore, COPD patients are at increased risk of complications following surgery. The purpose of this study was to evaluate the postoperative total hip arthroplasty (THA) outcomes of COPD patients. Specifically, we asked the following questions: (1) Is COPD associated with adverse perioperative outcomes and (2) Does COPD increase the risk of short-term complications following THA?

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 64,796 patients who underwent THA between 2008 and 2014. A total of 2426 patients with COPD were identified. COPD and non-COPD cohorts were compared based on the following outcomes: hospital length-of-stay, operative times, discharge disposition, and 30-day postoperative complications.

RESULTS

COPD patients were found to have a longer length-of-stay and be discharged to an extended care facility (P < .001). COPD patients were also at significantly (P < .05) increased risk for any complication, such as mortality, myocardial infarction, pneumonia, septic shock, unplanned reintubation, use of a mechanical ventilator >48 hours, deep infection, require a blood transfusion, return to operating room, and a readmission within 30 days postoperatively.

CONCLUSIONS

COPD patients are more likely to suffer from postoperative complications following THA when compared to non-COPD patients. Many of these complications are medical, pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients.

Total shoulder arthroplasty in octogenarians: Is there a higher risk of adverse outcomes?

This study used the National Surgical Quality Improvement Program to evaluate octogenarians who underwent total shoulder arthroplasty (TSA). Specifically, we evaluated: (1) patient demographics; (2) perioperative factors; and (3) 30-day postoperative complications. Compared to controls, the octogenarians had more females, white patients, lower BMIs, fewer smokers, less functionally independent, higher ASA scores, shorter operative times, and longer LOS. Octogenarians had greater odds for developing any (OR = 2.05; 95%CI, 1.70-2.46), any major (OR = 2.28; 95%CI, 1.66-3.13), and any minor (OR = 1.99; 95%CI, 1.63-2.45) complications. Perioperative risk management strategies for elective TSA in the elderly may help mitigate the increased perioperative risks associated with age.

The Influence of Patient Gender on Morbidity Following Total Hip or Total Knee Arthroplasty

BACKGROUND

Little research has focused on the influence of gender on postoperative morbidity following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study aimed to compare operative time, length of stay, 30-day complications, and readmissions based on patient gender.

METHODS

The prospectively collected National Surgical Quality Improvement Program registry from 2005 to 2014 was queried to identify primary elective THA and TKA patients. Multivariate regression was used to compare the rates of 30-day adverse events, rates of readmission, operative time, and postoperative length of stay between men and women. Multivariate analyses were controlled for baseline patient characteristics and procedure type.

RESULTS

A total of 173,777 patients were included (63.5% TKA and 36.5% THA). Male gender increased the risk of multiple adverse events, including death (relative risk [RR] 1.1, P < .001), surgical site infection (RR 1.2, P < .001), sepsis (RR 1.4, P < .001), cardiac arrest (RR 1.8, P < .001), and return to the operating room (RR 1.3, P < .001). Men had decreased overall adverse events (RR 0.8, P < .001) secondary to a lower risk of urinary tract infection (RR 0.5, P < .001) and blood transfusion (RR 0.7, P < .001), which were prevalent adverse events. Men had an increased risk of 30-day readmission (RR 1.2, P < .001), slightly increased operative time (+6 minutes, P < .001), and slightly decreased length of stay (-0.2 days, P < .001).

CONCLUSION

Men had increased risk of multiple individual adverse events including death, surgical site infection, cardiac arrest, return to the operating room, and readmission. Conversely, women had increased risk of urinary tract infection and blood transfusion.

Perioperative Outcomes and Complications in Patients With Heart Failure Following Total Knee Arthroplasty

BACKGROUND

Heart failure (HF) is a common comorbidity in the aging population and they will require major elective surgery. The purpose of this study is to determine if HF is a risk factor for adverse perioperative outcomes and short-term complications following total knee arthroplasty.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all patients who underwent total knee arthroplasty for osteoarthritis from 2008 to 2014. Any diagnosis other than osteoarthritis was excluded. A total of 111,634 patients were identified and 251 of these patients had a preoperative diagnosis of HF. The main outcomes included operative time, lengths-of-stay, discharge disposition, return to operating room, readmission, and short-term complications, including death.

RESULTS

Patients with HF were found to have longer hospital stays (β = 0.59, 95% confidence interval [CI] 0.12-1.06) following total knee arthroplasty, and were more likely to return to the operating room (odds ratio 2.00, 95% CI 1.01-3.94) and be readmitted (OR 1.88, 95% CI 1.21-2.94). In addition, HF was found to be a risk factor for 1 or more complications (OR 1.41, 95% CI 1.05-1.90), wound dehiscence (OR 4.86, 95% CI 1.68-14.03), and myocardial infarction (OR 4.81, 95% CI 1.90-12.16) postoperatively.

CONCLUSION

Patients with HF are more likely to have a longer length-of-stay, return to the operating room, and be readmitted. Additionally, they have a higher risk for at least one postoperative complication, myocardial infarction, and wound dehiscence.