Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Aspartate Aminotransferase-to-Platelet Ratio Index Suggestive of Liver Dysfunction Predicts Early Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

Aspartate aminotransferase-to-platelet ratio index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy, which is resource-intensive and invasive. The purpose of this study was to investigate the association between preoperative APRI and 30-day postoperative complications after isolated open reduction internal fixation (ORIF) of distal radius fractures (DRFs).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent isolated ORIF of DRFs between 2015 and 2021. The study population was divided into two groups on the basis of preoperative APRI: normal/reference (APRI, <0.5) and liver dysfunction (APRI, ≥0.5). Information on patient demographics, comorbidities, and 30-day postoperative complications after isolated ORIF of DRFs was collected. Multivariate logistic regression analysis was performed to investigate the relationship between preoperative APRI and postoperative complications.

Results

Compared to patients with normal APRI, patients with preoperative APRI associated with liver dysfunction were significant for male sex (P < .001), younger age (P < .001), American Society of Anesthesiologists classification grade ≥3 (P < .001), being smokers (P < .001), and having comorbid diabetes (P = .002) and bleeding disorders (P < .001). Preoperative APRI associated with liver dysfunction was independently associated with a greater likelihood of any complications (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.19-1.87; P < .001), nonhome discharge (OR, 1.62; 95% CI, 1.15-2.27; P = .005), and a length of stay of >2 days (OR, 1.70; 95% CI, 1.32-2.20; P < .001).

Conclusions

Aspartate aminotransferase-to-platelet ratio index values associated with liver dysfunction were associated with an increased rate of early postoperative complications after DRF ORIF.

Clinical relevance

This study suggests APRI's utility as a cost-effective, noninvasive measure of liver function that physicians can use before surgery to better identify surgical candidates with DRFs and suspicion of liver dysfunction.

Type of study/level of evidence

Prognostic III.

Low albumin-to-fibrinogen ratio predicts adverse clinical outcomes after primary total joint arthroplasty: A retrospective observational investigation

Nutritional markers for adverse clinical outcomes following total joint arthroplasty (TJA) remain controversial. This study attempted to explore the validity of the albumin-to-fibrinogen ratio (AFR) in nutritional assessment and assess its predictive value for adverse postoperative outcomes in patients receiving TJA. 2137 patients who underwent primary TJA between January 2016 and June 2021 were screened. We performed receiver operating characteristic curves and area under the curve (AUC) to assess predictive value and establish optimal thresholds. Multivariate regression models were then used to assess potential associations between AFR and adverse postoperative outcomes. AFR might predict postoperative deep surgical site infections (AUC = 0.699, P = .023). The optimal threshold for wound complications, determined by the Youden index, was 12.96. Compared with patients with reduced AFR, patients with high AFR exhibited an enhanced risk of adverse postoperative outcomes (adjusted OR: 4.010-8.832, all P < .05). Using multivariate Cox regression analysis, we further confirmed a higher risk of adverse postoperative outcomes in patients with low AFR (adjusted HR: 3.733-7.335, all P < .05). Reduced preoperative AFR markedly enhanced adverse postoperative outcomes. Hence, AFR may serve as a potential biomarker for nutritional assessment, and may predict postoperative wound complications following primary TJA.

Patient-Reported Outcome Measures: State of the Art in Patient-Reported Outcome Measure Application in Lower Extremity Orthopaedics

With an increasing shift toward a value-based and outcome-driven healthcare system, patient-reported outcome measures (PROMs) will continue to play a prominent role in assessing performance, making clinical decisions, shared decision making, and determining the comparative effectiveness of procedures such as total joint arthroplasty for lower extremity conditions, such as ankle, hip, and knee osteoarthritis. As the application of PROMs in evaluating surgical outcomes has evolved from that of a research setting to that of a clinical setting, their use in the decision-making process has become more prevalent. As a result, preoperative optimization, surgical indications, and improved outcomes after surgery have been greatly enhanced. To enable benchmarking, quality reporting, and performance measurement at an aggregate level, it is crucial to have a comprehensive PROM collection system. However, achieving this goal is contingent upon addressing the variability in reported PROMs and the patient-centered benchmarks used to analyze clinical significance.

Improved performance of machine learning models in predicting length of stay, discharge disposition, and inpatient mortality after total knee arthroplasty using patient-specific variables

BACKGROUND

This study aimed to compare the performance of ten predictive models using different machine learning (ML) algorithms and compare the performance of models developed using patient-specific vs. situational variables in predicting select outcomes after primary TKA.

METHODS

Data from 2016 to 2017 from the National Inpatient Sample were used to identify 305,577 discharges undergoing primary TKA, which were included in the training, testing, and validation of 10 ML models. 15 predictive variables consisting of 8 patient-specific and 7 situational variables were utilized to predict length of stay (LOS), discharge disposition, and mortality. Using the best performing algorithms, models trained using either 8 patient-specific and 7 situational variables were then developed and compared.

RESULTS

For models developed using all 15 variables, Linear Support Vector Machine (LSVM) was the most responsive model for predicting LOS. LSVM and XGT Boost Tree were equivalently most responsive for predicting discharge disposition. LSVM and XGT Boost Linear were equivalently most responsive for predicting mortality. Decision List, CHAID, and LSVM were the most reliable models for predicting LOS and discharge disposition, while XGT Boost Tree, Decision List, LSVM, and CHAID were most reliable for mortality. Models developed using the 8 patient-specific variables outperformed those developed using the 7 situational variables, with few exceptions.

CONCLUSION

This study revealed that performance of different models varied, ranging from poor to excellent, and demonstrated that models developed using patient-specific variables were typically better predictive of quality metrics after TKA than those developed employing situational variables.

LEVEL OF EVIDENCE

III.

Preoperative Risk Stratification in Arthroscopic Rotator Cuff Repair: Aspartate Aminotransferase-to-Platelet Ratio Index as an Estimate of Liver Dysfunction

BACKGROUND

Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy which is resource-intensive and invasive. This study investigates the association between various degrees of liver dysfunction based on APRI and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into four groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications.

RESULTS

Compared to normal liver function, mild fibrosis was significantly associated with male gender, lower BMI, American Society of Anesthesiologists (ASA) classification ≥ 3, and comorbid diabetes, hypertension, chronic obstructive pulmonary disease, and bleeding disorders. Significant fibrosis was significantly associated with male gender, greater BMI, ASA classification ≥ 3, and comorbid diabetes, hypertension, and bleeding disorders. Cirrhosis was significantly associated with younger age, ASA classification ≥ 3, smokers, and comorbid diabetes and bleeding disorders. Compared to normal liver function, fibrosis was not associated with complications, significant fibrosis was associated with myocardial infarction, and cirrhosis was associated with major complications, sepsis, non-home discharge, and mortality. However, mild fibrosis, significant fibrosis, and cirrhosis were independently associated with any adverse 30-day postoperative complications following aRCR.

CONCLUSION

Among those with predicted liver damage based on preoperative APRI, 30-day postoperative complications following aRCR were not found to be independently associated with preoperative mild fibrosis, significant fibrosis, or cirrhosis. Our results suggest that APRI predictive of liver dysfunction may be a weaker deterrent to undergoing aRCR compared to other orthopedic surgeries.

Comparison of Femoral Component Rotation between Robotic-Assisted vs. Soft-Tissue Tensor Total Knee Arthroplasty with Anatomic Implants

Background and Objectives: Total knee arthroplasty (TKA) is the most effective treatment method for end-stage osteoarthritis. One of the most important aspects of this surgery is adequate implant positioning, as it guarantees the desired outcome of restoring limb biomechanics. Surgical technique is being continuously improved along with hardware development. There are two novel devices designed to help establish proper femoral component rotation: soft-tissue tensor and robotic-assisted TKA (RATKA). This study compared the femoral component rotation achieved with the use of three methods: RATKA, soft tissue tensioner and the conventional measured-resection technique, all of them utilizing anatomical design prosthesis components. Materials and Methods: A total of 139 patients diagnosed with end-stage osteoarthritis underwent total knee arthroplasty between December 2020 and June 2021. After the surgery, they were divided into three groups depending on procedure technique and implant type: Persona (Zimmer Biomet) + Fuzion Balancer, RATKA + Journey II BCS or conventional TKA + Persona/Journey. Postoperatively, a computed tomography examination was performed in order to measure femoral component rotation. All three groups were compared independently during statistical analysis. Fisher's exact, Kruskal-Wallis and Dwass-Steel-Crichtlow-Fligner tests were used for particular calculations. Results: Statistically significant differences in femoral component rotation between groups were noticed. However, in terms of values other than 0° in external rotation, no significant variance was revealed. Conclusions: Additional total knee arthroplasty instruments seem to improve the outcomes of the surgery, providing better component positioning than in the conventional measured-resection technique based only on bone landmarks.

Relationships Between Preoperative Mental Health and Improvements in Patient-Reported Outcomes After Total Hip and Knee Arthroplasty

BACKGROUND

Poor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups.

METHODS

Elective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (≥75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoperative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately.

RESULTS

Median postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA, -4.0 high-THA, and -4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B = -0.94 - -0.68, P < .001-P = .01) but with improvements in joint health only in the low-THA group (B = -0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group.

CONCLUSION

Patients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and preoperative counseling.

The utility of machine learning algorithms for the prediction of patient-reported outcome measures following primary hip and knee total joint arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used as quality benchmark in total hip and knee arthroplasty (THA; TKA) due to bundled payment systems that aim to provide a patient-centered, value-based treatment approach. However, there is a paucity of predictive tools for postoperative PROMs. Therefore, this study aimed to develop and validate machine learning models for the prediction of numerous patient-reported outcome measures following primary hip and knee total joint arthroplasty.

METHODS

A total of 4526 consecutive patients (2137 THA; 2389 TKA) who underwent primary hip and knee total joint arthroplasty and completed both pre- and postoperative PROM scores was evaluated in this study. The following PROM scores were included for analysis: HOOS-PS, KOOS-PS, Physical Function SF10A, PROMIS SF Physical and PROMIS SF Mental. Patient charts were manually reviewed to identify patient demographics and surgical variables associated with postoperative PROM scores. Four machine learning algorithms were developed to predict postoperative PROMs following hip and knee total joint arthroplasty. Model assessment was performed through discrimination, calibration and decision curve analysis.

RESULTS

The factors most significantly associated with the prediction of postoperative PROMs include preoperative PROM scores, Charlson Comorbidity Index, American Society of Anaesthesiology score, insurance status, age, length of hospital stay, body mass index and ethnicity. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.83), calibration and decision curve analysis.

CONCLUSION

This study developed machine learning models for the prediction of patient-reported outcome measures at 1-year following primary hip and knee total joint arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four machine learning models, highlighting the potential of these models in clinical practice to inform patients prior to surgery regarding their expectations of postoperative functional outcomes following primary hip and knee total joint arthroplasty.

LEVEL OF EVIDENCE

Level III, case control retrospective analysis.

Pain and rehabilitation after total hip arthroplasty are approach dependent: a multisurgeon, single-center, prospective cohort study

PURPOSE

The aim of this study was to assess perioperative pain and mobilization after total hip arthroplasty (THA) using three different surgical approaches.

METHODS

This was a multisurgeon, prospective, single-center cohort study. A total of 188 patients who underwent hip arthroplasty (THA) between February 2019 and April 2019 were analyzed according to the surgical approach used (direct anterior, lateral, and posterior approach). Outcome parameters were the daily walking distance during the inpatient stay, the pain level according to the visual analog scale (VAS) at rest and motion during the inpatient stay and at 6-week follow-up and the modified Harris Hips Score (mHHS) preoperatively and at 6 weeks.

RESULTS

The walking distance within the groups increased significantly during the inpatient stay (p < 0.001). The DAA and posterior approach patients had a significantly longer walking distance than the lateral approach patients on the third postoperative day (DAA vs. lateral, p = 0.02; posterior vs. lateral 3, p = 0.03). DAA and posterior approach patients reported significantly less pain during motion on the third postoperative day and at 6-week follow-up than the lateral approach patients (3 postoperative day: DAA vs. lateral, p = 0.011; posterior vs. lateral, p = 0.04; 6 weeks control: DAA vs. lateral, p = 0.001; Posterior vs. lateral 3, p = 0.005). The mHHS demonstrated significant improvement within each group. However, lateral approach patients reported significantly less improvement than the DAA and posterior approach patients (DAA vs. lateral, p = 0.007; posterior vs. lateral, p = 0.021).

CONCLUSION

This study analyzed perioperative pain progression and short-term rehabilitation after THA according to the different surgical approaches. Direct anterior and posterior approaches have shown comparable improvements in pain, walking distance, and mHHS. Whether this effect persists over a longer period of time must be clarified in future studies.

STUDY DESIGN

Prospective cohort study, level of evidence, 2.

Is There Synergistic Effect Between Obesity and Hypoalbuminemia on Postoperative Outcomes Among Primary Total Shoulder Arthroplasty Recipients?

Background

Malnutrition and obesity are established predictors of complications following joint replacement surgery. However, the effect of obesity in the setting of albumin deficiency has not been explored in non-weight-bearing upper-extremity joint arthroplasty.

Purpose

We sought to determine whether there is a synergistic effect between obesity and hypoalbuminemia among patients undergoing primary total shoulder arthroplasty (TSA) with respect to postoperative outcomes, including (1) mortality rates, (2) composite surgical complications, (3) length of hospitalization, and (4) hospital readmission.

Methods

We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database to find patients who underwent primary TSA from January 1, 2006, to December 31, 2019. We grouped these patients as obese (body mass index [BMI] ≥ 30 kg/m2) or nonobese (BMI = 18.5-29.9 kg/m2) and by serum albumin level (hypoalbuminemia < 3.5 mg/dL or normoalbuminemia ≥ 3.5 mg/dL). We gathered data on readmission and mortality rates, and NSQIP complications were organized into 3 composite variables: wound infection, systemic infection, and cardiac/pulmonary complication. For each outcome, multivariate logistic regression analysis evaluated its association with obesity and hypoalbuminemia, as well as with the interaction of BMI and albumin, while adjusting for covariates.

Results

Of 12,881 patients, 51.8% were obese and 7.0% had hypoalbuminemia; 7.6% of obese patients had hypoalbuminemia versus 6.3% of those who were not obese. Patients with hypoalbuminemia had the longest hospital stays and the highest rates of mortality and systemic infection of all subgroups. Multivariate logistic regression analysis did not show higher complication rates due to obesity or evidence of additive interaction between hypoalbuminemia and obesity.

Conclusion

Unlike previous reports in weight-bearing arthroplasty, in this retrospective study of a cohort of patients who underwent TSA, we did not observe greater complications due to obesity alone, nor did we find evidence of additive interaction between obesity and hypoalbuminemia. This distinction may be due to the non-weight-bearing nature of TSA, in which excessive BMI may be less relevant for postoperative healing.

Preoperative Veterans Rand-12 Mental Composite Score of < 40 Leads to Increased Healthcare Utilization and Diminished Improvement After Primary Knee Arthroplasty

BACKGROUND

Adverse outcomes after total knee arthroplasty (TKA) have been associated with preoperative psychological disorders and poor mental health. We aimed to investigate and quantify the association between preoperative mental health and 1) postoperative 90-day health care utilization; and 2) 1-year patient-reported outcomes after primary TKA.

METHODS

Retrospective review of prospectively collected data of patients who underwent primary elective TKA (n = 7,476) was performed. Preoperative mental health was evaluated using Veterans Rand-12 Mental Composite Scores (VR-12 MCS). Outcomes included prolonged length of stay (>2-days), nonhome discharge, 90-day readmissions, emergency department visits, and reoperation. Improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) and Patient Acceptable Symptom State (PASS) achievement were evaluated at 1-year. Multivariable regression was implemented to explore associations between preoperative VR-12 MCS and outcomes of interest.

RESULTS

A total of 5,402 (72.3%) completed 1-year follow-up. Lower preoperative VR-12 MCS was associated with higher odds of prolonged length of stay (MCS 20-39: odds ratio (OR): 1.46;P < .001), and nonhome discharge disposition (MCS 20-39: OR: 1.92;P < .001), but not 90-day readmission or reoperation (MCS20-39; P = .12 and P = .64). At 1-year, patients with a lower MCS were less likely to attain a substantial clinical benefit in KOOS-pain (MCS 0-19; OR: 0.25; P < .001) and less likely to achieve PASS (MCS20-39; OR: 0.74; P = .002). Patients with an MCS >60 were more likely to be discharged home (OR: 1.42; P = .008), achieve substantial clinical benefit in their KOOS-JR (OR: 1.16; P = .027),-Pain (OR: 1.220; P = .007) and PASS at 1-year (OR: 1.28; P = .008).

CONCLUSIONS

Lower VR-12 MCS is associated with increased postoperative health care utilization and worse patient-reported outcome measures at 1-year post-TKA. These findings suggest that a VR-12 MCS ≤40 could be used to designate increased risk, guide the preoperative discussion and potential interventions.

Comparative Analysis of the Ability of Machine Learning Models in Predicting In-hospital Postoperative Outcomes After Total Hip Arthroplasty

BACKGROUND

Machine learning (ML) methods have shown promise in a wide range of applications including the development of patient-specific predictive models before surgical interventions. The purpose of this study was to develop, test, and compare four distinct ML models to predict postoperative parameters after primary total hip arthroplasty.

METHODS

Data from the Nationwide Inpatient Sample were used to identify patients undergoing total hip arthroplasty from 2016 to 2017. Linear support vector machine (LSVM), random forest (RF), neural network (NN), and extreme gradient boost trees (XGBoost) predictive of mortality, length of stay, and discharge disposition were developed and validated using 15 predictive patient-specific and hospital-specific factors. Area under the curve of the receiver operating characteristic (AUCROC) curve and accuracy were used as validity metrics, and the strongest predictive variables under each model were assessed.

RESULTS

A total of 177,442 patients were included in this analysis. For mortality, the XGBoost, NN, and LSVM models all had excellent responsiveness during validation while RF had fair responsiveness. LSVM had the highest responsiveness with an AUCROC of 0.973 during validation. For the length of stay, the LSVM and NN models had fair responsiveness while the XGBoost and random forest models had poor responsiveness. LSVM had the highest responsiveness with an AUCROC of 0.744 during validation. For the discharge disposition outcome, LSVM had good responsiveness while the XGBoost, NN, and RF models all had fair responsiveness. LSVM had the highest responsiveness with an AUCROC of 0.801.

DISCUSSION

The ML methods tested demonstrated a range of poor-to-excellent responsiveness and accuracy in the prediction of the assessed metrics, with LSVM being the best performer. Such models should be further developed, with eventual integration into clinical practice to inform patient discussions and management decision making, with the potential for integration into tiered bundled payment models.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Vitamin D3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine if a one-time dose of vitamin D₃ prior to total knee arthroplasty improves function and patient-reported outcomes, while decreasing complications.

METHODS

One hundred seven patients undergoing primary total knee arthroplasty were randomized to receive 50,000 international units vitamin D₃ (57 patients) or placebo (50 patients) on the morning of surgery. Power analysis determined 45 patients were required in each cohort to detect a minimal clinically important difference of 6 points in the functional component of the 2011 version of the Knee Society Score (KSS), assuming an alpha of 0.05 and power of 80%. KSS and a Timed Up and Go Test (TUGT) were measured preoperatively and at 3 and 6 weeks postoperatively.

RESULTS

There was no difference in improvement of KSS at 3 weeks (+4.8 points vitamin D₃ versus +3.0 points placebo; P = .6) or 6 weeks (+14.5 points vitamin D₃ versus +12.4 points placebo; P = .5) from baseline. There was no difference in change in TUGT at 3 weeks (+1.2 seconds vitamin D₃ versus +0.6 seconds placebo; P = .6) or 6 weeks (-0.3 seconds vitamin D₃ versus -0.9 seconds placebo; P = .6) from baseline. There were 4 complications in the placebo cohort within the first 90 days postoperatively and 5 complications in the vitamin D₃ cohort (P = 1.0).

CONCLUSION

Supplementation with 50,000 international units vitamin D₃ on the day of surgery failed to demonstrate statistical significant differences in functional KSS, TUGT times, or complications in the early postoperative period compared to placebo.

LEVEL OF EVIDENCE

Level I, therapeutic study.

A Comparison of Revision Rates and Dislocation After Primary Total Hip Arthroplasty with 28, 32, and 36-mm Femoral Heads and Different Cup Sizes: An Analysis of 188,591 Primary Total Hip Arthroplasties

This article was updated on August 17, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1462, in the first sentence of the Abstract section entitled "Results," the phrase that had read "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003), but more dislocations than 32-mm heads (HR for >2 weeks = 2.25 [95% CI, 1.13 to 4.49]; p = 0.021)" now reads "and 36-mm heads had fewer dislocations than 28-mm (HR = 0.33 [95% CI, 0.16 to 0.68]; p = 0.003) and 32-mm heads (HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88]; p = 0.021)." On page 1468, in the last sentence of the section entitled "Acetabular Components with a Diameter of <51 mm," the phrase that had read "and HR for ≥2 weeks = 2.25 [95% CI, 1.13 to 4.49; p = 0.021]) ( Fig. 3 )" now reads "and HR for ≥2 weeks = 0.44 [95% CI, 0.22 to 0.88; p = 0.021]) ( Fig. 3 )." Finally, on page 1466, in the upper right corner of Figure 3 , under "32mm vs 36mm," the second line that had read "2Wks+: HR=2.25 (1.13, 4.49), p=0.021" now reads "2Wks+: HR=0.44 (0.22, 0.88), p= 0.021."

Evaluating methodological quality of prognostic prediction models on patient reported outcome measurements after total hip replacement and total knee replacement surgery: a systematic review protocol

BACKGROUND

Prediction models for poor patient-reported surgical outcomes after total hip replacement (THR) and total knee replacement (TKR) may provide a method for improving appropriate surgical care for hip and knee osteoarthritis. There are concerns about methodological issues and the risk of bias of studies producing prediction models. A critical evaluation of the methodological quality of prediction modelling studies in THR and TKR is needed to ensure their clinical usefulness. This systematic review aims to (1) evaluate and report the quality of risk stratification and prediction modelling studies that predict patient-reported outcomes after THR and TKR; (2) identify areas of methodological deficit and provide recommendations for future research; and (3) synthesise the evidence on prediction models associated with post-operative patient-reported outcomes after THR and TKR surgeries.

METHODS

MEDLINE, EMBASE, and CINAHL electronic databases will be searched to identify relevant studies. Title and abstract and full-text screening will be performed by two independent reviewers. We will include (1) prediction model development studies without external validation; (2) prediction model development studies with external validation of independent data; (3) external model validation studies; and (4) studies updating a previously developed prediction model. Data extraction spreadsheets will be developed based on the CHARMS checklist and TRIPOD statement and piloted on two relevant studies. Study quality and risk of bias will be assessed using the PROBAST tool. Prediction models will be summarised qualitatively. Meta-analyses on the predictive performance of included models will be conducted if appropriate. A narrative review will be used to synthesis the evidence if there are insufficient data to perform meta-analyses.

DISCUSSION

This systematic review will evaluate the methodological quality and usefulness of prediction models for poor outcomes after THR or TKR. This information is essential to provide evidence-based healthcare for end-stage hip and knee osteoarthritis. Findings of this review will contribute to the identification of key areas for improvement in conducting prognostic research in this field and facilitate the progress in evidence-based tailored treatments for hip and knee osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021271828.

In Revision THA, Is the Re-revision Risk for Dislocation and Aseptic Causes Greater in Dual-mobility Constructs or Large Femoral Head Bearings? A Study from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Dislocation is one of the most common causes of a re-revision after a revision THA. Dual-mobility constructs and large femoral head bearings (≥ 36 mm) are known options for mitigating this risk. However, it is unknown which of these choices is better for reducing the risk of dislocation and all-cause re-revision surgery. It is also unknown whether there is a difference between dual-mobility constructs and large femoral head bearings according to the size of the acetabular component.

QUESTIONS/PURPOSES

We used data from a large national registry to ask: In patients undergoing revision THA for aseptic causes after a primary THA performed for osteoarthritis, (1) Does the proportion of re-revision surgery for prosthesis dislocation differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (2) Does the proportion of re-revision surgery for all aseptic causes differ between revision THAs performed with dual-mobility constructs and those performed with large femoral head bearings? (3) Is there a difference when the results are stratified by acetabular component size?

METHODS

Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were analyzed for 1295 first-revision THAs for aseptic causes after a primary THA performed for osteoarthritis. The study period was from January 2008-when the first dual-mobility prosthesis was recorded-to December 2019. There were 502 dual-mobility constructs and 793 large femoral head bearings. There was a larger percentage of women in the dual-mobility construct group (67% [334 of 502]) compared with the large femoral head bearing group (51% [402 of 793]), but this was adjusted for in the statistical analysis. Patient ages were similar for the dual-mobility construct group (67 ± 11 years) and the large femoral head group (65 ± 12 years). American Society of Anesthesiologists (ASA) class and BMI distributions were similar. The mean follow-up was shorter for dual-mobility constructs at 2 ± 1.8 years compared with 4 ± 2.9 years for large femoral head bearings. The cumulative percent revision (CPR) was determined for a diagnosis of prosthesis dislocation as well as for all aseptic causes (excluding infection). Procedures using metal-on-metal bearings were excluded. The time to the re-revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or database closure at the time of analysis. The unadjusted CPR was estimated each year of the first 5 years for dual-mobility constructs and for each of the first 9 years for large femoral head bearings, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The apparent shorter follow-up of the dual-mobility construct group relates to the more recent increase in dual-mobility numbers recorded in the registry. The results were adjusted for age, gender, and femoral fixation. Results were subanalyzed for acetabular component sizes < 58 mm and ≥ 58 mm, set a priori on the basis of biomechanical and other registry data.

RESULTS

There was no difference in the proportion of re-revision for prosthesis dislocation between dual-mobility constructs and large femoral head bearings (hazard ratio 1.22 [95% CI 0.70 to 2.12]; p = 0.49). At 5 years, the CPR of the re-revision for prosthesis dislocation was 4.0% for dual mobility constructs (95% CI 2.3% to 6.8%) and 4.1% for large femoral head bearings (95% CI 2.7% to 6.1%). There was no difference in the proportion of all aseptic-cause second revisions between dual-mobility constructs and large femoral head bearings (HR 1.02 [95% CI 0.76 to 1.37]; p = 0.89). At 5 years, the CPR of dual-mobility constructs was 17.6% for all aseptic-cause second revision (95% CI 12.6% to 24.3%) and 17.8% for large femoral head bearings (95% CI 14.9% to 21.2%). When stratified by acetabular component sizes less than 58 mm and at least 58 mm, there was no difference in the re-revision CPR for dislocation or for all aseptic causes between dual-mobility constructs and large femoral head bearings.

CONCLUSION

Either dual-mobility constructs or large femoral head bearings can be used in revision THA, regardless of acetabular component size, as they did not differ in terms of re-revision rates for dislocation and all aseptic causes in this registry study. Longer term follow-up is required to assess whether complications develop with either implant or whether a difference in revision rates becomes apparent. Ongoing follow-up and comparison in a registry format would seem the best way to compare long-term complications and revision rates. Future studies should also compare surgeon factors and whether they influence decision-making between prosthesis options and second revision rates. Nested randomized controlled trials in national registries would seem a viable option for future research.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Artificial Neural Networks Can Predict Early Failure of Cementless Total Hip Arthroplasty in Patients With Osteoporosis

BACKGROUND

Total hip arthroplasty (THA) done in the aging population is associated with osteoporosis-related complications. The altered bone density in osteoporotic patients is a risk factor for revision surgery. This study aimed to develop and validate machine learning (ML) models to predict revision surgery in patients with osteoporosis after primary noncemented THA.

METHODS

We retrospectively reviewed a consecutive series of 350 patients with osteoporosis (T-score less than or equal to -2.5) who underwent primary noncemented THA at a tertiary referral center. All patients had a minimum 2-year follow-up (range: 2.1 to 5.6). Four ML algorithms were developed to predict the probability of revision surgery, and these were assessed by discrimination, calibration, and decision curve analysis.

RESULTS

The overall incidence of revision surgery was 5.2% at a mean follow-up of 3.7 years after primary noncemented THA in osteoporotic patients. Revision THA was done because of periprosthetic fracture in nine patients (50%), aseptic loosening/subsidence in five patients (28%), periprosthetic joint infection in two patients (11%) and dislocation in two patients (11%). The strongest predictors for revision surgery in patients after primary noncemented THA were female sex, BMI (>35 kg/m2), age (>70 years), American Society of Anesthesiology score (≥3), and T-score. All four ML models demonstrated good model performance across discrimination (AUC range: 0.78 to 0.81), calibration, and decision curve analysis.

CONCLUSION

The ML models presented in this study demonstrated high accuracy for the prediction of revision surgery in osteoporotic patients after primary noncemented THA. The presented ML models have the potential to be used by orthopaedic surgeons for preoperative patient counseling and optimization to improve the outcomes of primary noncemented THA in osteoporotic patients.

Predictive capacity of four machine learning models for in-hospital postoperative outcomes following total knee arthroplasty

Background

Machine learning (ML) methods have shown promise in the development of patient-specific predictive models prior to surgical interventions. The purpose of this study was to develop, test, and compare four distinct ML models to predict postoperative parameters following primary total knee arthroplasty (TKA).

Methods

Data from the Nationwide Inpatient Sample was used to identify patients undergoing TKA during 2016-2017. Four distinct ML models predictive of mortality, length of stay (LOS), and discharge disposition were developed and validated using 15 predictive patient and hospital-specific factors. Area under the curve of the receiver operating characteristic curve (AUCROC) and accuracy were used as validity metrics, and the strongest predictive variables under each model were assessed.

Results

A total of 305,577 patients were included. For mortality, the XGBoost, neural network (NN), and LSVM models all had excellent responsiveness during validation, while random forest (RF) had fair responsiveness. For predicting LOS, all four models had poor responsiveness. For the discharge disposition outcome, the LSVM, NN, and XGBoost models had good responsiveness, while the RF model had poor responsiveness. LSVM and XGBoost had the highest responsiveness for predicting discharge disposition with an AUCROC of 0.747.

Discussion

The ML models tested demonstrated a range of poor to excellent responsiveness and accuracy in the prediction of the assessed metrics, with considerable variability noted in the predictive precision between the models. The continued development of ML models should be encouraged, with eventual integration into clinical practice in order to inform patient discussions, management decision making, and health policy.

What Can We Learn From Surgeons Who Perform THA and TKA and Have the Lowest Revision Rates? A Study from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Long-term implant survivorship in THA and TKA involves a combination of factors related to the patient, the implants used, and the decision-making and technical performance of the surgeon. It is unclear which of these factors is the most important in reducing the proportion of revision surgery.

QUESTIONS/PURPOSES

We used data from a large national registry to ask: In patients receiving primary THA and TKA for a diagnosis of osteoarthritis, do (1) the reasons for revision and (2) patient factors, the implants used, and the surgeon or surgical factors differ between surgeons performing THA and TKA who have a lower revision rate compared with all other surgeons?

METHODS

Data were analyzed for all THA and TKA procedures performed for a diagnosis of osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from September 1, 1999, when collection began, to December 31, 2018. The AOANJRR obtains data on more than 98% of joint arthroplasties performed in Australia. The 5-year cumulative percent revision (CPR) was identified for all THAs and TKAs performed for a diagnosis of osteoarthritis with 95% confidence intervals (overall CPR); the 5-year CPR with 95% CIs for each surgeon was calculated for THA and TKA separately. For surgeons to be included in the analysis, they had to have performed at least 50 procedures and have a 5-year CPR. The 5-year CPR with 95% CIs for each THA and TKA surgeon was compared with the overall CPR. Two groups were defined: low revision rate surgeons (the upper confidence level for a given surgeon at 5 years is less than 3.84% for THA and 4.32% for TKA), and all other surgeons (any surgeon whose CPR was higher than those thresholds). The thresholds were determined by setting a cutoff at 20% above the upper confidence level for that class. The approach we used to define a low revision rate surgeon was similar to that used by the AOANJRR for determining the better-performing prostheses and is recommended by the International Prosthesis Benchmarking Working Group. By defining the groups in this way, a significant difference between these two groups is created. Determining a reason for this difference is the purpose of presenting the proportions of different factors within each group. The study group for THA included 116 low revision rate surgeons, who performed 88,392 procedures (1619 revised, 10-year CPR 2.7% [95% CI 2.6% to 2.9%]) and 433 other surgeons, who performed 170,094 procedures (6911 revised, 10-year CPR 5.9% [95% CI 5.7% to 6.0%]). The study group for TKA consisted of 144 low revision rate surgeons, who performed 159,961 procedures (2722 revised, 10-year CPR 2.6% [95% CI 2.5% to 2.8%]) and 534 other surgeons, who performed 287,232 procedures (12,617 revised, 10-year CPR 6.4% [95% CI 6.3% to 6.6%]). These groups were defined a priori by their rate of revision, and the purpose of this study was to explore potential reasons for this observed difference.

RESULTS

For THA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for dislocation, followed by component loosening and fracture in patients treated by low revision rate surgeons. For TKA, the difference in overall revision rate between low revision rate surgeons and other surgeons was driven mainly by fewer revisions for aseptic loosening, followed by instability and patellofemoral complications in patients treated by low revision rate surgeons. Patient-related factors were generally similar between low revision rate surgeons and other surgeons for both THA and TKA. Regarding THA, there were differences in implant factors, with low revision rate surgeons using fewer types of implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR. Low revision rate surgeons used a higher proportion of hybrid fixation, although cementless fixation remained the most common choice. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 THA procedures per year, while other surgeons were more likely to perform fewer than 50 THA procedures per year. In general, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed each year, although low revision rate surgeons, on average, had more years of experience and performed more cases per year. Regarding TKA, there were more differences in implant factors than with THA, with low revision rate surgeons more frequently performing patellar resurfacing, using an AOANJRR-identified best-performing prosthesis combination (with the lowest rates of revision), using fewer implants that have been identified as having a higher-than-anticipated rate of revision within the AOANJRR, using highly crosslinked polyethylene, and using a higher proportion of cemented fixation compared with other surgeons. For surgeon factors, low revision rate surgeons were more likely to perform more than 100 TKA procedures per year, whereas all other surgeons were more likely to perform fewer than 50 procedures per year. Again, generally, the groups of surgeons (low revision rate surgeons and other surgeons) differed less in terms of years of surgical experience than they did in terms of the number of cases they performed annually, although low revision rate surgeons, on average, had more years of experience and performed more cases per year.

CONCLUSION

THAs and TKAs performed by surgeons with the lowest revision rates in Australia show reductions in all of the leading causes of revision for both THA and TKA, in particular, causes of revision related to the technical performance of these procedures. Patient factors were similar between low revision rate surgeons and all other surgeons for both THA and TKA. Low revision rate THA surgeons were more likely to use cement fixation selectively. Low revision rate TKA surgeons were more likely to use patella resurfacing, crosslinked polyethylene, and cemented fixation. Low revision rate THA and TKA surgeons were more likely to use an AOANJRR-identified best-performing prosthesis combination and to use fewer implants identified by the AOANJRR as having a higher-than-anticipated revision rate. To reduce the rate of revision THA and TKA, surgeons should consider addressing modifiable factors related to implant selection. Future research should identify surgeon factors beyond annual case volume that are important to improving implant survivorship.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Should patient age thresholds dictate fixation strategy in total hip arthroplasty?

AIMS

Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost.

METHODS

In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA.

RESULTS

Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation.

CONCLUSION

While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206-211.

Do Patient Engagement Platforms in Total Joint Arthroplasty Improve Patient-Reported Outcomes?

BACKGROUND

Web-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs).

METHODS

We performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized.

RESULTS

Of the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P < .001, P < .003), had higher body mass index (P = .024, P = .011), and had a higher household income (P < .001, P < .001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013).

CONCLUSION

There is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients.

Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery

BACKGROUND

Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications.

METHODS AND FINDINGS

A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68-3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59-5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17-3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85-10.00, p = 0.15).

CONCLUSIONS

We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines.

Does the anatomic design of total knee prosthesis allow for a better component fit than its nonanatomic predecessor? A matched cohort Study

Background

Total knee arthroplasty (TKA) is considered the most efficient treatment of end-stage osteoarthritis. There is an ongoing debate about proper implant designs and articulation types. One of the considered causes of unsatisfactory outcome and patients’ dissatisfaction is femoral or tibial component overhanging, which can lead to chronic knee pain and restricted motion. The aim of this study is to compare radiological outcomes of TKA using an anatomic PERSONA Posterior-Stabilized (PS) knee design with its nonanatomic predecessor, the NexGen LPS.

Methods

A group of 39 patients who received the PERSONA PS system and 33 patients who received the NexGen LPS was included. PERSONA patients were matched to NexGen patients using a 0.1 propensity score threshold with priority given to exact matches. Anteroposterior, lateral, and long-leg radiographs were taken preoperatively and at 6 weeks postoperatively to perform radiological and statistical analysis.

Results

The PERSONA subgroup had statistically higher posterior condylar offset. There is no statistically significant difference in posterior condylar offset ratio. There were less cases of femoral notching, femoral overhang, and placing tibial baseplate in the medial overhang in the PERSONA PS subgroup than in the NexGen subgroup (each statistically significant). Occurrence of tibial underhang was not statistically significant.

Conclusion

Radiological assessment in short-term follow-up showed excellent results for PERSONA knee design with better fit to native femur and tibia. In comparison to its predecessor, it also spares more bone tissue. As the aforementioned parameters are risk factors of lesser clinical outcomes, the PERSONA design gives high hopes for improvement of TKA satisfaction rate.

Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty

Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.

Diabetes Mellitus Is Not a Negative Prognostic Factor for Patients Undergoing Hip Arthroscopy

Diabetes mellitus (DM) has been associated with inferior clinical outcomes and comorbidities in general. The authors sought to compare the outcomes of hip arthroscopy at minimum 2-year follow-up for patients with DM with those of patients without DM. Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between February 2008 and December 2014. The inclusion criteria were patients with DM who underwent hip arthroscopy for the treatment of femoroacetabular impingement and labral tears and had preoperative patient- reported outcomes. The exclusion criteria were preoperative Tönnis grade greater than 1, previous ipsilateral hip surgery, and/or previous conditions. All patients with DM were matched in a 1:2 ratio to control patients without DM. The matching criteria were age at surgery, sex, body mass index, workers' compensation, capsular treatment, and acetabular Outerbridge grade 0 or 1 vs 2, 3, or 4. Of 29 eligible patients with DM, 26 (89.7%) had minimum 2-year follow-up. Twenty-six patients with DM were matched and compared with 52 patients without DM. Acetabuloplasty was performed more frequently in the control group (P=.01). There were no other statistically significant differences detected in terms of demographics, preoperative radiographic imaging, intraoperative findings, procedures, preoperative scores, follow-up scores, revision rates, rates of conversion to total hip arthroplasty, or complication rates. Patients with DM demonstrated favorable improvements at 2 or more years after arthroscopic labral treatment when compared with a matched control group without DM. The DM group demonstrated a non-statistically significant trend toward inferior outcomes in all patient-reported outcomes, visual analog scale score, and satisfaction. [Orthopedics. 2021;44(4):241-248.].

Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis

INTRODUCTION

The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry.

METHODS

Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes.

RESULTS

A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition.

DISCUSSION

Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients.

LEVEL OF EVIDENCE

Level III, retrospective study.

Is the Preoperative Use of Antidepressants and Benzodiazepines Associated with Opioid and Other Analgesic Use After Hip and Knee Arthroplasty?

BACKGROUND

Mental health disorders can occur in patients with pain conditions, and there have been reports of an increased risk of persistent pain after THA and TKA among patients who have psychological distress. Persistent pain may result in the prolonged consumption of opioids and other analgesics, which may expose patients to adverse drug events and narcotic habituation or addiction. However, the degree to which preoperative use of antidepressants or benzodiazepines is associated with prolonged analgesic use after surgery is not well quantified.

QUESTION/PURPOSES

(1) Is the preoperative use of antidepressants or benzodiazepine medications associated with a greater postoperative use of opioids, NSAIDs, or acetaminophen? (2) Is the proportion of patients still using opioid analgesics 1 year after arthroplasty higher among patients who were taking antidepressants or benzodiazepine medications before surgery, after controlling for relevant confounding variables? (3) Does analgesic drug use decrease after surgery in patients with a history of antidepressant or benzodiazepine use? (4) Does the proportion of patients using antidepressants or benzodiazepines change after joint arthroplasty compared with before?

METHODS

Of the 10,138 patients who underwent hip arthroplasty and the 9930 patients who underwent knee arthroplasty at Coxa Hospital for Joint Replacement, Tampere, Finland, between 2002 and 2013, those who had primary joint arthroplasty for primary osteoarthritis (64% [6502 of 10,138] of patients with hip surgery and 82% [8099 of 9930] who had knee surgery) were considered potentially eligible. After exclusion of another 8% (845 of 10,138) and 13% (1308 of 9930) of patients because they had revision or another joint arthroplasty within 2 years of the index surgery, 56% (5657 of 10,138) of patients with hip arthroplasty and 68% (6791 of 9930) of patients with knee arthroplasty were included in this retrospective registry study. Patients who filled prescriptions for antidepressants or benzodiazepines were identified from a nationwide drug prescription register, and information on the filled prescriptions for opioids (mild and strong), NSAIDs, and acetaminophen were extracted from the same database. For the analyses, subgroups were created according to the status of benzodiazepine and antidepressant use during the 6 months before surgery. First, the proportions of patients who used opioids and any analgesics (that is, opioids, NSAIDs, or acetaminophen) were calculated. Then, multivariable logistic regression adjusted with age, gender, joint, Charlson Comorbidity Index, BMI, laterality (unilateral/same-day bilateral), and preoperative analgesic use was performed to calculate odds ratios for any analgesic use and opioid use 1 year postoperatively. Additionally, the proportion of patients who used antidepressants and benzodiazepines was calculated for 2 years before and 2 years after surgery.

RESULTS

At 1 year postoperatively, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for any analgesics than were patients without a history of antidepressant or benzodiazepine use (adjusted odds ratios 1.9 [95% confidence interval 1.6 to 2.2]; p < 0.001 and 1.8 [95% CI 1.6 to 2.0]; p < 0.001, respectively). Similarly, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for opioids than patients without a history of antidepressant or benzodiazepine use (adjusted ORs 2.1 [95% CI 1.7 to 2.7]; p < 0.001 and 2.0 [95% CI 1.6 to 2.4]; p < 0.001, respectively). Nevertheless, the proportion of patients who filled any analgesic prescription was smaller 1 year after surgery than preoperatively in patients with a history of antidepressant (42% [439 of 1038] versus 55% [568 of 1038]; p < 0.001) and/or benzodiazepine use (40% [801 of 2008] versus 55% [1098 of 2008]; p < 0.001). The proportion of patients who used antidepressants and/or benzodiazepines was essentially stable during the observation period.

CONCLUSION

Surgeons should be aware of the increased risk of prolonged opioid and other analgesic use after surgery among patients who were on preoperative antidepressant and/or benzodiazepine therapy, and they should have candid discussions with patients referred for elective joint arthroplasty about this possibility. Further studies are needed to identify the most effective methods to reduce prolonged postoperative opioid use among these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Vitamin D Trajectory after Total Knee Arthroplasty: A Method for Quick Correction in Deficient Patients

Backgroud

It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA.

Methods

Vit D levels < 30 ng/mL are considered insufficient. We prospectively enrolled 60 patients (20 per group): group I, vit D sufficient patients; group II, vit D insufficient patients given IM supplementation (cholecalciferol 6,00,000 IU); and group III, vit D insufficient patients given oral supplementation (cholecalciferol 600,000 IU). Vit D levels, knee flexion, Timed Up and Go (TUG) test results, and visual analog scale (VAS) score were recorded preoperatively and postoperatively on day 3 and 14.

Results

In group I, mean preoperative vit D significantly dropped at postoperative day (POD) 3 and POD 14 (p = 0.001). In group II, mean preoperative vit D rose at POD 3 and rose significantly at POD 14 (p = 0.001). In group III, mean preoperative vit D increased significantly at both POD 3 and POD 14 (p < 0.001). Also, in group III, the rise in vit D was significantly higher than that in group II both at POD 3 and POD 14 (p < 0.05). In group III, 19 of 20 insufficient patients became sufficient on POD 3 and all 20 by POD 14. In group II, even by POD 14, only 11 of 20 insufficient patients became sufficient. Functional parameters (flexion, change in flexion, TUG test results, and VAS score) were comparable (p > 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p < 0.05), suggesting a slower recovery. It remained comparable (p > 0.05) between group III and group I.

Conclusions

We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

Influence of Anxiety/Depression, Age, Gender and ASA on 1-Year Follow-Up Outcomes Following Total Hip and Knee Arthroplasty in 5447 Patients

Introduction: There are many factors influencing the outcome after total joint arthroplasty (TJA). In particular, patient-related factors such as age, gender, ASA (American Society of Anesthesiologists), or preoperative anxiety/depression have become increasingly important. The aim of this study was to examine the association of these parameters with 1-year postoperative outcomes after total knee and total hip arthroplasty (TKA, THA). Methods: A retrospective cohort of 5447 TJA patients was evaluated by pre- and postoperative analysis of EQ-5D, EQ-VAS and WOMAC Score. Furthermore, major focus was put on the association between age, gender, ASA, preoperative anxiety/depression and outcome parameters. Results: 53.3% (2903/5447) of all patients were identified with anxiety/depression at time of surgery. In the analysis, patients without anxiety/depression showed statistically significantly (p < 0.05) better EQ-5D, EQ-VAS and WOMAC scores. In addition, patients with ASA 2 or 3 and age over 70 years showed statistically significantly (p < 0.01) worse EQ-5D and WOMAC scores. Gender did not influence the postoperative EQ-5D and WOMAC results, but men had significantly better EQ-VAS scores than women in this study. Conclusion: Preoperative anxiety/depression symptoms show worse clinical outcomes 1 year postoperatively after TJA. Other outcome-influencing factors are higher age and ASA 2 or 3. In the future, such patients should be identified, and as far as applicable, a treatment of anxiety/depression or comorbidities should be implemented preoperatively of the surgical procedure to improve clinical outcomes.

Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?

BACKGROUND

Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m², had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups.

RESULTS

Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m², albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality.

CONCLUSION

Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization.

LEVEL OF EVIDENCE

Retrospective cohort study, level IV.

Patient Satisfaction After Lower Extremity Total Joint Arthroplasty: An Analysis of Medical Comorbidities and Patient Demographics

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey has received increased attention to determine which demographics may influence patient satisfaction after Total Hip and Knee Arthroplasty. The purpose of this study was to evaluate the various effects that patient-specific factors, medical comorbidities, and demographics had on patient satisfaction. Two thousand and ninety-two patients underwent lower extremity total joint arthroplasty at our institution between 2014 and 2018. Nine hundred twenty-three of these patients responded to their HCAHPS survey (44%). Most patients (609, 66%) underwent primary total knee arthroplasty followed by 244 (26.4%) total hip arthroplasties, 35 (3.8%) revision total knee arthroplasties, 28 (3.0%) bilateral total knee arthroplasties, and 7 (0.8%) revision total hip arthroplasties. Increasing age and length of stay were associated with a decrease in patient satisfaction whereas patients who were married reported higher satisfaction. Patients discharged to a rehabilitation facility had a 12% decrease in top-box response rate compared to those discharged home. Contrary to our hypothesis, specific procedure type and the presence of comorbidities failed to predict patient satisfaction. The results of this study shed light on the intricate relationship between patient satisfaction and patient-specific factors. Furthermore, health care workers can counsel patients on expected satisfaction when considering total hip and knee arthroplasty.

[Decision for total hip arthroplasty-the surgeons' view]

BACKGROUND

The decision for total hip arthroplasty (THA) is based on pain, loss of function, radiological changes and failed conservative therapy. These criteria are rarely based on systematic research and have not been integrated in generally accepted treatment guidelines. Aim of our study was, therefore, to analyse which decision criteria German orthopaedic and trauma surgeons use in order to recommend THA for patients with hip osteoarthritis.

MATERIALS AND METHODS

From 10/2019 to 07/2020 we conducted a nation-wide survey among 218 orthopaedic and trauma surgeons about their criteria for and against THA surgery, as well as their treatment objectives.

RESULTS

147 fully completed questionnaires were analysed. Pain (99%), limitation of movement (99%), as well as impairment of walking distance (97%), and the subjective burden (97%) were the most frequent criteria. 97% and 96% of surgeons consider prescription of analgesics and physical therapy, as well as a lack of their effectiveness, as criteria for THA. 87% see radiological changes grade Kellgren & Lawrence III as threshold. A recommendation against surgery is triggered by obesity (BMI ≥ 40 kg/m²) in 48% and by the presence of an active infection in 96%.

CONCLUSIONS

Current surgeons' practice criteria of recommendations for THA in Germany seem to reflect widely nationally and internationally discussed recommendations. Particular attention is given to patient factors like pain, loss of function and subjective burden, as well as previous conservative treatment and contraindications, like poorly controlled diabetes or an active infection, whereas morbid obesity is not seen as contraindication by all surgeons.

Meta-analysis of retrospective studies suggests that the pre-operative opioid use is associated with an increased risk of adverse outcomes in total hip and or knee arthroplasty

BACKGROUND

Opioid use is prevalent in the general population. This systematic review and meta-analysis sought to evaluate whether it affects patient-reported outcomes (PROs) following total hip or knee arthroplasty.

METHODS

The following databases were systematically searched on February 5, 2020: Medline, Embase (Ovid), Cochrane Library, and Web of Science. Studies were included if they compared patients who received opioids or not before total hip or knee arthroplasty. Outcomes of interest were rates of post-operative revision, peri-prosthetic infection, and readmission.

RESULTS

Ten retrospective studies were included for review. Pre-operative opioid use was identified as a risk factor for post-operative revision [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.15-1.73, p<0.01], peri-prosthetic infection (OR 1.36, 95% CI 1.08-1.71, p=0.01), and readmission (OR 1.41, 95% CI 1.20-1.75, p<0.01).

CONCLUSION

The available evidence indicates that pre-operative opioid use increases the risk of adverse outcomes following total hip or knee arthroplasty. Orthopedic physicians should consider these risks when treating their patients.

Evaluation of Dislocation Risk Factors With Total Hip Arthroplasty in Developmental Hip Dysplasia Patients: A Multivariate Analysis

BACKGROUND

This study aimed to investigate the risk factors for dislocation in patients diagnosed with developmental dysplasia of the hip (DDH) who underwent total hip arthroplasty.

METHODS

We retrospectively reviewed 40 patients who developed dislocation and compared them with 400 patients in the control group without hip instability. Patients-, surgery-, and implant-related factors were investigated. Risk factors were evaluated using multivariate logistic regression.

RESULTS

The mean follow-up period was 32.3 months. The mean time to dislocation was 4.4 months. There were 7 men (17.5%) and 33 women (82.5%) in the dislocation group and 83 men (20.7%) and 317 women (79.3%) in the control group (P = .627). Diabetes mellitus (DM; P = .032) and history of previous hip surgery for DDH were associated with dislocation (P < .001). The subtrochanteric shortening osteotomy (P = .001), acetabular inclination (P = .037), acetabular anteversion (P < .001), femoral head size (P < .001), and postoperative infection (P = .003) were associated with dislocation. Major predictors of hip dislocation after total hip arthroplasty in patients with DDH were previous hip surgery (odds ratio [OR], 6.76; 95% confidence interval [CI], 1.86-24.6; P = .004), high hip center (OR, 2.90; 95% CI, 1.31-6.38; P = .008), DM (OR, 2.68; 95% CI, 1.06-6.80; P = .037), and acetabular inclination (OR, 2.62; 95% CI, 1.09-6.26; P = .03).

CONCLUSION

Patients with DM and previous hip surgery should be informed about increased dislocation rates. Using a larger head diameter and restoration of the true hip rotation center are essential to prevent hip dislocation in these patients. Furthermore, accurate positioning of the acetabular inclination and anteversion are also important.

The Cost of Poor Mental Health in Total Joint Arthroplasty

BACKGROUND

The purpose of this analysis was to evaluate (1) the impact of depression on resource utilization and financial outcomes in bundled total joint arthroplasty (TJA) and (2) whether similar effects are seen using baseline patient-reported outcome scores.

METHODS

All elective bundled TJA cases from 2017 to 2018 at an academic system in the New York City area were included. We analyzed variables associated with cost differences seen between patients with and without depression, and between patients with low (<40th percentile) and high baseline (>60th percentile) Veterans RAND 12-Item Health Survey mental component scores (MCSs). We also analyzed whether depression or low MCS could predict worse financial outcomes.

RESULTS

Our population included 825 patients, 418 with patient-reported outcome scores data. Depression was associated with higher rates of skilled nursing facility (SNF) discharge (42.7% vs 36.5%, P = .04), SNF payments ($16,200 vs $12,100, P = .0002), and average total episode costs ($31,000 vs $27,000, P = .04). Depression predicted bundle cost to be greater than target price (OR 1.82, 95% CI: 1.04-.16; P = .04) and SNF payment greater than 75th percentile (OR: 1.91; 95% CI: 1.00-3.65; P < .05). Similar effects were not seen using MCS.

CONCLUSION

This is the first study to determine that depression predicts bundle cost greater than target price and SNF payment greater than 75th percentile. Our results emphasize the importance of accurate preoperative assessment of mental health in optimization of care, focusing on attenuating the increased SNF payments associated with depression. As similar effects were not seen using MCS, future studies should analyze the use of validated screening tools for depression, such as the PHQ-9, for more accurate assessments of patient mental health in TJA.

Investigating the True Effect of Psychological Variables Measured Prior to Arthroplastic Surgery on Postsurgical Outcomes: A P-Curve Analysis

Patients' presurgical psychological profiles have been posited to predict pain and function following arthroplastic surgery of the hip and knee. Nevertheless, findings are conflicting, and this may be rooted in biased reporting that makes the determination of evidential value difficult. This ambiguity may have negative consequences for researchers and governmental agencies, as these rely on findings to accurately reflect reality. P-Curve analyses were used to establish the presence of evidential value and selective reporting in a sample of studies examining the effect of presurgical psychological predictors on outcomes following knee and hip arthroplastic surgery. A systematic search of the literature revealed 26 relevant studies. The examined sets of studies indicate that there is evidential value for the effect of depression on pain intensity and function, anxiety on pain intensity and function, pain catastrophizing on pain intensity, as well as the combined effects of all psychological predictors on pain intensity and function. The presence of evidential value was inconclusive for the effect of optimism on pain intensity. There were no signs that any results were influenced by biased reporting. The results highlight the importance of patients' psychological profiles in predicting surgical outcomes, which represent a promising avenue for future treatment approaches. PERSPECTIVE: The effects of P-hacking are difficult to detect and might be at the root of conflicting findings pertaining to the predictive properties of presurgical psychological variables on postsurgical outcomes. P-Curve analysis allows the determination of evidential value underlying these relationships and detection of P-hacking to ensure that findings are not the result of selective reporting.

Impact of Obesity on Outcomes of Patients With Hip Osteoarthritis Who Underwent Hip Arthroplasty

Background

While obesity has been clearly established as a risk factor for osteoarthritis (OA), there is a scarcity of studies comparing outcomes between obese and non-obese patients with hip OA who underwent hip arthroplasty.

Methods

This study involved adults with hip OA who had hip replacement procedures. Data was sourced from the Nationwide Inpatient Sample (NIS) database for 2016 and 2017. The primary outcome was inpatient mortality. Secondary outcomes included the development of non-ST segment elevation myocardial infarction (NSTEMI), sepsis, post-procedure site infection, pneumonia, acute kidney failure, deep vein thrombosis (DVT), pulmonary embolism, need for transfusion of blood products, complications involving orthopedic devices as well as mean length of hospitalization and mean total hospital charges.

Results

Obese patients did not have higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.65, 95% CI 0.303-1.381, p=0.260), had increased mean length of hospitalization (0.11, 95% CI 0.083-0.134, p<0.001) and higher odds of developing DVT (aOR: 1.62, 95% CI 1.187-2.222, p<0.001), acute kidney failure (aOR: 1.64, 95% CI: 1.488-1.807, p<0.001) and pressure-related injuries (aOR: 1.64, 95% CI 1.081-2.483, p=0.020), compared with non-obese patients. Obese patients were found to have a lower aOR of having NSTEMI (aOR: 0.57, 95% CI 0.332-0.986, p=0.044), and need for blood product transfusion (aOR: 0.80, 95% CI 0.726-0.875, p<0.001).

Conclusion

Although there is no difference in mortality among obese and non-obese patients who had hip arthroplasty, obese adults have increased odds of morbidity and perioperative complications. Hence, obese adults likely require better perioperative management to decrease the incidence of these complications.

Parkinson Disease Associated Differences in Elective Orthopedic Surgery Outcomes: A National Readmissions Database Analysis

Background:

Advances in the treatment of Parkinson’s disease (PD) have allowed for improvements in mortality and quality survival, making the management of comorbid conditions of aging, such as osteoarthritis, crucial.

Objective:

To determine the extent to which PD impacts hospitalization outcomes after an elective orthopedic procedure.

Methods:

This retrospective cohort study used data from the National Readmissions Database and included adults ages 40 and above with and without PD. Primary outcomes included length of stay of the index admission, discharge disposition and 30-day readmission. Logistic regression was used to compare the odds of readmission for PD patients compared to non-PD. Clinical conditions associated with readmission were compared between the two groups.

Results:

A total of 4,781 subjects with PD and 947,475 subjects without PD met inclusion criteria. Length of stay (LOS) during the index admission was longer for PD patients. PD patients were much more likely to be discharged to inpatient post-acute care (49.3% vs 26.2%) while non-PD subjects were more likely to be discharged home with (31.9% [PD] vs 44.8% [non-PD]) or without home health (18.7% [PD] vs 28.9% [non-PD]). A total of 271 PD patients (5.66%) and 28,079 non-PD patients (2.96%) were readmitted within 30 days following surgery. After adjusting for age, sex, socioeconomic status, expected payer, comorbidities, index admission LOS, year and discharge disposition, PD subjects were 31% more likely to be readmitted than non-PD subjects (AOR 1.31, 1.07–1.62).

Conclusions:

Parkinson’s disease patients were readmitted more often than non-PD patients, although the rate of readmission was still low.

Impact of Diabetes Mellitus on Outcomes of Patients With Knee Osteoarthritis Who Underwent Knee Arthroplasty: An Analysis of the Nationwide Inpatient Sample

Background

Knee arthroplasty is one of the most common reasons for hospitalizations in the United States. Diabetes mellitus is thought to be associated with adverse perioperative outcomes. We sought to demonstrate the effect of comorbid diabetes on hospitalizations involving patients with knee osteoarthritis who had knee arthroplasty.

Materials and methods

Data was obtained from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. ICD-10 codes were used to obtain a cohort of patient who were principally admitted for knee osteoarthritis who underwent knee arthroplasty. The patients were further divided according to diabetic status. The primary outcome compared inpatient mortality. Secondary outcomes included mean length of hospital stay, total hospital charges, presence of secondary diagnoses on discharge of acute kidney injury, surgical site infection, sepsis, thromboembolic events, non-ST segment elevation myocardial infarction (NSTEMI).

Results

Patients with diabetes mellitus had a lower adjusted odds ratio for mortality (aOR: 0.45 95% CI: 0.221 - 0.920, p = 0.029), with no significant difference in total hospital charges and length of hospital stay. Interestingly, patients with diabetes had lower odds of NSTEMI; 0.53 (95% CI: 0.369 - 0.750, p < 0.001) sepsis; 0.64 (95% CI: 0.449 - 0.924, p = 0.017) and DVT; 0.67 (95% CI: 0.546 - 0.822, p < 0.001).

Conclusion

Uncomplicated diabetes mellitus is not associated with adverse outcomes in patients hospitalized with knee osteoarthritis who had knee arthroplasty.

Anxiety and Osteoarthritis Disability: Updated Overview and Commentary

Introduction:

Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.

Objective:

In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.

Methods:

Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.

Results:

Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.

Conclusion:

This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model

BACKGROUND

Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA).

METHODS

A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion.

RESULTS

Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%.

CONCLUSION

This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BACKGROUND

Research has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.

METHODS

TJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.

RESULTS

About 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission.

CONCLUSION

Screening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

BACKGROUND

Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.

QUESTIONS/PURPOSES

(1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points?

METHODS

During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14.

RESULTS

In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019).

CONCLUSIONS

Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Impact of Co-Morbidities on the Cost of Care in Primary Elective Joint Arthroplasty

BACKGROUND

The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients.

METHODS

A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models.

RESULTS

The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs.

CONCLUSION

The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.