Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty

Alcohol and drug use in adults younger than 60 years with hip fracture - A comparison of validated instruments and the clinical eye: A prospective multicenter cohort study of 218 patients

BACKGROUND

It is a common preconception that young individuals sustaining hip fractures have alcohol and/or drug use disorder. It is important to evaluate the actual use to avoid complications and plan the rehabilitation.

AIM

The primary objective was to assess alcohol and drug consumption in hip fracture patients <60 years using the validated Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT) scores. We secondarily investigated the agreement between the instruments and the physicians' clinical evaluation of usage.

MATERIAL AND METHODS

This is a sub-study of 91 women and 127 men from a multicenter cohort study of patients with an acute hip fracture treated at four hospitals in Denmark and Sweden. AUDIT and DUDIT forms were completed by the patients. In addition, the researchers made an evaluation of the patients' alcohol/drug use based on direct patient contact and information on previous alcohol/drug use from medical charts. AUDIT ranges 0-40 with 6 (women) and 8 (men) as the cut-off for hazardous use. DUDIT ranges 0-44 with cut-offs of 2 and 6 indicating drug-related problems.

RESULTS

According to the AUDIT, 29 % of the patients had a hazardous alcohol use (25 % women, 31 % men), whilst the clinical evaluation identified 26 % (24 % women, 28 % men). However, there was a low agreement between "the clinical eye" and AUDIT, as the clinical evaluation only correctly identified 35 of 56 individuals with AUDIT-scores indicating hazardous alcohol use. DUDIT equaled drug related problems in 8 % (5 % women, 10 % men), the clinical evaluation depicted 8 % with drug related problems (4 % women, 10 % men). The agreement was low between "the clinical eye" and DUDIT; only 7 of 15 with DUDIT-scores indicating drug related problems were correctly identified.

CONCLUSION

Hazardous alcohol consumption is more common in non-elderly hip fracture patients than in the general population. Considering both self-reported alcohol use and clinical evaluation, women have almost as high rate as men. DUDIT indicated drug related problems to be slightly more common than in the population. Still, a majority did not exhibit troublesome use of neither alcohol nor drugs. The two screening methods do not identify the same individuals, and further investigation in clinical practice is needed.

Eight of ten patients return to daily activities, work, and sports after total knee arthroplasty

BACKGROUND

Besides return to work (RTW) and return to sports (RTS), patients also prefer to return to daily activities (RTA) such as walking, sleeping, grocery shopping, and domestic work following total knee arthroplasty (TKA). However, evidence on the timelines and probability of patients' RTA is sparse.

AIM

To assess the percentage of patients able to RTA, RTW, and RTS after TKA, as well as the timeframe and influencing factors of this return.

METHODS

A retrospective cohort study with prospectively collected data was conducted at a medium-sized Dutch orthopedic hospital. Assessments of RTA, RTW, and RTS were performed at 3 mo and/or 6 mo following TKA. Investigated factors encompassed patient characteristics, surgical characteristics, and preoperative patient-reported outcomes.

RESULTS

TKA patients [n = 2063; 66 years old (interquartile range [IQR]: 7 years); 47% male; 28 kg/m2 (IQR: 4 kg/m2)] showed RTA ranging from 28% for kneeling to 94% for grocery shopping, with 20 d (IQR: 27 d) spent for putting on shoes to 74 d (IQR: 57 d) for kneeling. RTW rates varied from 62% for medium-impact work to 87% for low-impact work, taking 33 d (IQR: 29 d) to 78 d (IQR: 55 d). RTS ranged from 48% for medium-impact sports to 90% for low-impact sports, occurring within 43 d (IQR: 24 d) to 90 d (IQR: 60 d). One or more of the investigated factors influenced the return to each of the 14 activities examined, with R² values ranging from 0.013 to 0.127.

CONCLUSION

Approximately 80% of patients can RTA, RTW, and RTS within 6 mo after TKA. Return is not consistently influenced by predictive factors. Results help set realistic pre- and postoperative expectations.

Ninety-day postoperative mortality and complications in continuous and unselected single-stage revisions for chronic periprosthetic joint infection

PURPOSE

Single-stage revision has gained significant attention as a major surgical approach for periprosthetic joint infection (PJI). However, the 90-day mortality and complication profile of single-stage revision is poorly characterized. The purposes of this study were to determine the incidence rates of and identify the risk factors for 90-day postoperative mortality and complications of single-stage revision for chronic PJI.

METHODS

A retrospective review was conducted on patients who underwent single-stage revision for PJI between August 2000 and May 2022. Patient demographics, 90-day mortality, and postoperative complications were recorded. Complications were categorized into systemic and local complications. Patients in this study were further categorized into knee and hip revision groups. Univariate and multivariate logistic regression analyses were performed to identify significant independent predictors of the outcome measures.

RESULTS

348 patients (144 knees and 204 hips) were included in this study. The 90-day mortality rate was 0.9%. The incidence rates of postoperative complications in knee and hip surgeries were 31.3% and 19.6%, respectively. The most common complication was deep-vein thrombosis (DVT). Rheumatoid arthritis (RA) was the independent predictor of mortality. In the knee revision group, fungal infection was identified as the independent predictor of recurrent PJI; regular alcohol use was predictive of wound dehiscence. Among hip PJI patients, age ≥ 80 years was independently associated with DVT; RA was found to be a predictor of dislocation and wound dehiscence.

CONCLUSION

For continuous and unselected patients with chronic PJI, single-stage revision demonstrated a satisfactory 90-day mortality. Nevertheless, the 90-day postoperative complication rates after single-stage revision in both knee and hip groups were relatively high.

The association of alcohol use disorder with revision rates and post-operative complications in total shoulder arthroplasty

Background

Alcohol use disorder (AUD) is the most prevalent substance use disorder in the United States. However, the current literature on AUD as a preoperative risk factor for Total Shoulder Arthroplasty (TSA) outcomes is limited. The purpose of this study was to identify the association of AUD with revision rates and 90-day postoperative complications in TSA.

Methods

A retrospective study was conducted using the PearlDiver database. Patients diagnosed with AUD were identified. Patients in remission or with underlying cirrhosis were excluded. Outcomes included 2-year revision, 90-day readmission, 90-day emergency, and 90-day post-operative medical complications. Analysis was performed with univariate chi-squared tests followed by multivariable logistic regression.

Results

A total of 59,261 patients who underwent TSA for osteoarthritis were identified, with 1522 patients having a diagnosis of AUD. Multivariable logistic regression showed that patients with AUD were more likely to undergo 2-year all-cause revision (OR = 1.49, p  =  0.007), 2-year aseptic revision (OR = 1.47, p  =  0.014), 90-day hospital readmission (OR = 1.57, p  =  0.015), and 90-day transient mental disorder (OR = 2.13, p  =  0.026).

Conclusions

AUD is associated with increased rates of 2-year revision surgery, as well as 90-day readmission and 90-day transient mental disorder following primary TSA for osteoarthritis. These findings may assist orthopedic surgeons in counseling patients with AUD during the pre-operative course.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Biopsychosocial complexity in patients scheduled for elective TKA surgery: A feasibility pilot study with the INTERMED self-assessment questionnaire

OBJECTIVE

Primary aim; to determine the feasibility of implementation of the INTERMED Self-Assessment (IM-SA) in adult patients scheduled for total knee arthroplasty (TKA). Secondary aim; to measure biopsychosocial complexity, referral to psychiatry or psychology in cases of complexity and to gain insight into the relation between biopsychosocial complexity and length of stay (LOS), method of discharge (MOD) and polypharmacy.

METHODS

A feasibility study was conducted with 76 participants in a general hospital in the Netherlands. Feasibility was determined by the number of completed questionnaires, time spent completing the questionnaire and the attitude of staff and patients towards the IM-SA. A cut off point ≥19 on the IM-SA was used to determine the prevalence of biopsychosocial complexity. A case file study was performed to check if referral to psychiatry or psychology had taken place. The Spearman's Rank Correlation Coefficient or Phi was used to determine if there was a relation between biopsychosocial complexity and LOS, MOD and polypharmacy.

RESULTS

All participants completed the IM-SA. The average time spent completing the questionnaire was 11.46 min (SD 5.74). The attitude towards the IM-SA was positive. The prevalence of biopsychosocial complexity was 11.84%. Referral to psychiatry or psychology did not take place. There was no relation between complexity and LOS (Spearman's rho (r) = 0.079, p = 0.499, MOD (Phi = 0.169, p = 0.173) and polypharmacy (Phi = 0.007, p = 0.953).

CONCLUSION

Biopsychosocial complexity can be identified in TKA patients during the pre-operative phase by using the IM-SA. Implementation of the IM-SA in a Dutch general hospital is feasible.

The Association Between Mental Health, Substance Use Disorder, and Outcomes After Total Joint Arthroplasty

BACKGROUND

Prior studies suggest that distressed patients or those who have poor mental health have inferior postoperative outcomes when compared to nondistressed patients. However, these studies typically do not account for substance use or other comorbidities often found in this population, which can independently contribute to postoperative complications. This study sought to control for these factors and assess if a diagnosis of a mental health condition is directly associated with worse outcomes after total joint arthroplasty.

METHODS

A retrospective chart review was performed for 3,182 patients who underwent a total hip arthroplasty and 4,430 patients who underwent a total knee arthroplasty. Diagnosis of the mental health disorders included depression, anxiety disorder, adjustment disorder, bipolar disorder, trauma, stressor-related disorder, and schizophrenia or schizoaffective disorder. Multivariable analyses were performed to control for alcohol use, drug use, tobacco use, body mass index, and a comorbidity index.

RESULTS

When controlling for body mass index and Charlson comorbidity index, no statistically significant associations were found between a diagnosis of any mental health condition or a specific diagnosis of depression or anxiety, and 90-day readmission, reoperation, or 1 year mortality for patients undergoing total knee arthroplasty or total hip arthroplasty.

CONCLUSIONS

When accounting for confounding factors, there does not appear to be a direct association between diagnosis of any of the psychiatric conditions we studied and outcomes after primary total joint arthroplasty. While prior studies suggest addressing the mental health condition may improve outcomes, this study suggests that preoperative medical optimization and potentially addressing substance use may be more effective strategies.

Hypothyroidism Impacts Clinical and Healthcare Utilization Outcomes After Primary Total Hip Arthroplasty

BACKGROUND

Our objective was to assess the association of hypothyroidism with outcomes of primary total hip arthroplasty (THA) overall and stratified by underlying diagnosis.

METHODS

We identified patients undergoing primary THA in a national database from 2016 to 2020. We stratified them based on primary diagnoses into hip osteoarthritis (OA; N = 1,761,960), osteonecrosis (ON; N = 78,275), traumatic fracture (N = 532,910), inflammatory arthritis (IA; N = 3,520), and "other" (N = 90,550). We identified hypothyroidism and complications using secondary diagnoses. Among 2,467,215 patients undergoing primary THA, mean age was 68 years (range, 18 to 90), and 58.3% were women. Complications codes only included initial encounters. We performed time-trends analyses and multivariable-adjusted regression analyses adjusted for demographics, expected primary payer, a comorbidity score, elective versus non-elective admission, and hospital characteristic information, with clinical and healthcare utilization outcome as endpoints.

RESULTS

Overall, hypothyroidism was significantly associated with increased LOS, total charges, non-routine discharges, blood transfusions, and prosthetic fractures. In the OA cohort, hypothyroidism was associated with increased LOS, total charges, and non-routine discharges (P < .001 for each), and blood transfusions (P = .02). Hypothyroidism was associated with increased total charges (P = .001) in the ON cohort and with increased LOS, non-routine discharge, and blood transfusion (P < .05 each) in the traumatic fracture cohort.

CONCLUSIONS

Hypothyroidism was associated with blood transfusions, prosthetic fractures, and utilization outcomes in THA patients. Tailored intervention strategies for hypothyroidism should be tested for their efficacy to improve THA peri-operative outcomes.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use

Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.

Cannabis Use Does Not Affect Outcomes After Total Hip Arthroplasty

BACKGROUND

Cannabis use in patients undergoing arthroplasty has increased with ongoing legalization throughout the United States. The purpose of this study was to report total hip arthroplasty (THA) outcomes in patients self-reporting cannabis use.

METHODS

There were 74 patients who underwent primary THA from January 2014 to December 2019 at a single institution with minimum 1-year follow-up who had their self-reported cannabis use retrospectively reviewed. Patients who had a history of alcohol or illicit drug abuse were excluded. A match control was conducted based on age; body mass index; sex; Charlson Comorbidity Index; insurance status; and use of nicotine, narcotics, antidepressants, or benzodiazepines to patients undergoing THA who did not self-report cannabis use. Outcomes included Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score for Joint Reconstruction (HOOS JR), in hospital morphine milligram equivalents (MMEs) consumed, outpatient MMEs prescribed, in hospital lengths of stay (LOS), postoperative complications, and readmissions.

RESULTS

There was no difference in the preoperative, postoperative, or change in Harris Hip Score or HOOS JR between cohorts. There was also no difference in hospital MMEs consumed (102.4 versus 101, P = .92), outpatient MMEs prescribed (119 versus 156, P = .11) or lengths of stay (1.4 versus 1.5 days, P = .32). Also, readmissions (4 versus 4, P = 1.0) and reoperations (2 versus 1, P = .56) were not different between groups.

CONCLUSION

Self-reported cannabis use does not influence 1-year outcomes after THA. Further studies are warranted to determine the efficacy and safety of perioperative cannabis use after THA to help guide orthopaedic surgeons in counseling patients.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care

Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.

Outcomes of total hip and knee arthroplasty in special populations: a synopsis and critical appraisal of systematic reviews

INTRODUCTION

This study aimed to present and critically appraise the best available evidence investigating associations between some pre-defined patient-related characteristics and perioperative complications or other outcomes in THA and TKA.

METHODS

Electronic databases were searched (Medline, EMBASE, Scopus, CENTRAL) for systematic reviews assessing the following pre-defined patient-related characteristics as possible risk factors for worse peri-operative outcomes in THA and TKA: smoking, alcohol excess, rheumatoid arthritis, human immunodeficiency virus infection, hepatitis C virus infection, mental health conditions, and solid organ transplantation. Our primary outcome was periprosthetic joint infection. Results were analysed separately for THA, TKA and THA/TKA (mixed data).

RESULTS

Based on at least two systematic reviews being in agreement, the following patient-related characteristics were associated with increased incidence of complications as follows: a) Smoking for all-cause revision in THA, for periprosthetic joint infection in TKA and THA/TKA; b) alcohol excess for periprosthetic joint infection in THA/TKA; c) human immunodeficiency virus for periprosthetic joint infection in THA/TKA; d) hepatitis C virus for overall complications, periprosthetic joint infection and all-cause revision in THA and THA/TKA, and for overall complications in TKA. Our study found conflicting evidence for a) smoking as a risk factor for periprosthetic joint infection and aseptic loosening in THA; b) human immunodeficiency virus as a risk factor for all-cause revision for THA/TKA; c) hepatitis C virus as a risk factor for periprosthetic joint infection and all-cause revision in TKA. No certainty of evidence was assigned to these results as this was not assessed by the authors of the majority of the included systematic reviews.

CONCLUSION

We found that smoking, excess alcohol consumption, RA, and infection with HIV and HCV were associated with a higher incidence of periprosthetic joint infection in one or both of THA and TKA or mixed THA/TKA data. All our results should be interpreted and communicated to patients with caution as the quality of the included systematic reviews was generally poor.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Effect of documented and undocumented psychiatric conditions on length of stay and discharge destination after total knee arthroplasty

INTRODUCTION

Length of stay (LOS) and readmissions are quality metrics linked to physician payments and substantially impact the cost of care. This study aims to evaluate the effect of documented and undocumented psychiatric conditions on LOS, discharge location, and readmission following total knee arthroplasty (TKA).

METHODS

Retrospective review of all primary, unilateral TKA from 2015 to 2020 at a high-volume, academic orthopedic hospital was conducted. Patients were separated into three cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, discharge location, and 90 days readmissions were assessed.

RESULTS

A total of 2935 patients were included; 1051 patients had no recorded psychiatric medications (control); 1884 patients took at least one psychiatric medication, of which 1161 (61.6%) were in the-Dx and 723 (38.4%) were in the +Dx cohort. Operative time (+Dx, 103.4 ± 29.1 and -Dx, 103.1 ± 28.5 vs. 93.6 ± 26.2 min, p < 0.001 for both comparisons) and hospital LOS stay (+ Dx, 3.00 ± 1.70 and -Dx, 3.01 ± 1.83 vs. 2.82 ± 1.40 days, p = 0.021 and p = 0.006, respectively) were greater for patients taking psychiatric medications when compared to the control group. Patients taking psychiatric medication with or without associated diagnosis were significantly more likely to be discharged to a secondary facility-22.8% and 20.9%, respectively-compared to controls, at 12.5% (p < 0.001). Ninety-day readmission rates did not differ between the control and both psychiatric groups (p = 0.693 and p = 0.432, respectively).

CONCLUSION

TKA patients taking psychiatric medications with or without a documented psychiatric diagnosis have increased hospital LOS and higher chances of discharge to a secondary facility. Most patients taking psychiatric medication also had no associated diagnosis. Payment models should consider the presence of undocumented psychiatric diagnoses when constructing metrics. Surgeons and institutions should also direct their attention to identifying, recording, and managing these patients to improve outcomes.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Cannabis use disorder is associated with shorter length of stay and increased home discharge after primary total joint arthroplasty: a propensity-weighted analysis

INTRODUCTION

Increased legalization of cannabis use across the United States has been correlated with increased cannabis use in the clinical setting. However, little is known regarding the characteristics and postoperative outcomes after primary joint arthroplasty (TJA) for patients with cannabis use disorder (CUD).

METHODS

This retrospective cohort study used data from the National Inpatient Sample of patients undergoing primary TJA between 2006 to 2015. Patients were grouped based on presence of concomitant CUD. Patient demographic characteristics and outcome data between groups were analyzed. Propensity score methodology was used to compare immediate in-hospital complications and economic outcomes.

RESULTS

A total of 8,740,798 TJAs were included. The prevalence of CUD increased nearly five-fold from 0.05% to 0.26% during this time (P < 0.0001). CUD patients were significantly younger, more likely to be male, most frequently of non-Hispanic Black race, and had higher rates of Medicaid insurance. Patients with CUD had a significantly shorter length of hospital stay (3.04 vs. 3.24 days, P = 0.0297), while incurring significantly higher daily ($22,614 vs. $17,955, P < 0.0001) and total charges during admission ($58,507 vs. $50,924, P < 0.0001), compared to patients without CUD. When compared with the control group, CUD was associated with significantly greater odds of home discharge (odds ratio (OR): 1.45, P = 0.0007), and significantly lower odds of rehab discharge (OR: 0.70, P = 0.0013). There were no differences in overall complication profile or in the vast majority of individual in-hospital complications between groups.

CONCLUSION

While CUD is correlated to shorter length of stay and increased home discharge after TJA, it does not show a strong effect on complications in an inpatient postoperative setting. It is important for clinicians to appreciate the demographic profile and expected clinical and economic outcomes for patients with CUD undergoing TJA, particularly in the context of evolving laws surrounding cannabis use.

A national analysis of the effect alcohol use disorder has on short-term complications and readmissions following total shoulder arthroplasty

Background

Alcohol use disorder has been associated with broad health consequences that may interfere with healing after total shoulder arthroplasty. The aim of this study was to explore the impact of alcohol use disorder on readmissions and complications following total shoulder arthroplasty.

Methods

We used data from the Healthcare Cost and Utilization Project National Readmissions Database (NRD) from 2016 to 2018. Patients were included based on International Classification of Diseases, 10th Revision (ICD-10) procedure codes for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). Patients with an alcohol use disorder (AUD) were identified using the ICD-10 diagnosis code F10.20. Demographics, complications, and 30-day and 90-day readmission were collected for all patients. A univariate logistic regression was performed to investigate AUD as a factor affecting readmission and complication rates. A multivariate logistic regression model was created to assess the impact of alcohol use disorder on complications and readmission while controlling for demographic factors.

Results

In total, 164,527 patients were included, and 503 (0.3%) patients had a prior diagnosis of AUD. Revision surgery was more common in patients with an alcohol use disorder (8.8% vs. 6.2%; p = 0.022). Postoperative infection (p = 0.026), dislocation (p = 0.025), liver complications (p < 0.01), and 90-day readmission (p < 0.01) were more common in patients with a diagnosed AUD. On multivariate analysis, patients with an AUD were found to be at increased odds for liver complications (OR: 46.8; 95% CI: [32.8, 66.8]; p < 0.01). Comparatively, mean age, length of stay, and over healthcare costs were also higher for patients with an AUD.

Conclusion

Patients with a diagnosis of AUD were more likely to suffer from shoulder dislocation, liver complications, and 90-day readmission, while also being younger and having longer hospital stays. Therefore, surgeons should take caution to anticipate and prevent complications and readmissions following total shoulder arthroplasty in patients with an AUD.

Bacteremia in Patients Undergoing Debridement, Antibiotics, and Implant Retention Leads to Increased Reinfections and Costs

Background

Debridement, antibiotics, and implant retention (DAIR) is a common treatment for acute prosthetic joint infection (PJI). The effects of concurrent bacteremia at the time of DAIR are poorly understood. This study sought to determine whether patients with bacteremia at the time of DAIR have higher reinfection rates.

Material and methods

A retrospective review of a national database was performed. Patients treated with DAIR (hip or knee arthroplasty) after a diagnosis of PJI were identified. DAIR patients who also had a diagnosis of bacteremia were matched to patients without bacteremia by comorbidities and Charlson Comorbidity Index score. The primary outcome was reinfection or continued infection at 90 days and 6, 12, and 24 months after DAIR. Ninety-day Medicare charges were compared between groups. Survival probabilities were used for survival comparisons.

Results

A total of 9945 patients underwent DAIR after a diagnosis of PJI. Seven hundred seven patients underwent DAIR with an associated diagnosis of bacteremia. Three hundred thirty-four DAIR patients with bacteremia were successfully matched to patients without bacteremia by age, gender, and comorbidities. DAIR survivorship was significantly worse in those with bacteremia at 90 days (51.5% vs 65.9%) and 6 (43.1% vs 60.5%), 12 (36.5% vs 56.0%), and 24 months (32.6% vs 53.3%) after DAIR. The 90-day costs of DAIR were significantly greater in PJI patients with bacteremia (mean: $14,722 standard deviation: $4086 vs mean: $8,052, standard deviation: $4,153, P < .01).

Conclusions

Patients undergoing DAIR with bacteremia are at an increased risk of reinfection or continued infection. Ninety-day costs are significantly increased (over 50%) in patients with bacteremia vs those without bacteremia.

Minor effect of patient education for alcohol cessation intervention on outcomes after acute fracture surgery: a randomized trial of 70 patients

BACKGROUND AND PURPOSE

High alcohol intake is associated with increased risk of postoperative complications. Alcohol cessation intervention is recommended prior to elective surgery. We investigated short- and long-term effects of perioperative intensive alcohol intervention in relation to acute ankle fracture surgery.

PATIENTS AND METHODS

70 patients requiring ankle fracture surgery and consuming ≥ 21 drinks weekly (1 drink = 12 g ethanol) were randomized to a manual-based 6-week intensive standardized alcohol cessation program, the Gold Standard Program (GSP-A), or treatment as usual (TAU), on the day of operation. GSP-A included 5 personal meetings, patient education, and motivational and pharmacological support (alcohol withdrawal prophylaxis, B vitamins, and low-dose disulfiram). Complications requiring treatment were measured after 6 weeks and 1 year. Alcohol intake was validated by biomarkers. Quality of life (QoL) was measured by the SF-36. Hospital costs were obtained from the National Hospital Costs Register.

RESULTS

Postoperatively, complete alcohol cessation was higher in the GSP-A than in the TAU group (18/35 vs. 5/35, number needed to treat = 3, p ≤ 0.001), but not lowrisk consumption in the long term (10/35 vs. 7/33, p = 0.5). Number of complications in the short and long term (12/35 vs. 14/33, 16/35 vs. 18/33), the SF-36 score, or hospital costs in the short and long term (€6,294 vs. €8,024, €10,662 vs. €12,198), were similar between the groups.

INTERPRETATION

Despite an effect on alcohol cessation and a positive tendency as regards the other outcomes, the postoperative complications, QoL, and costs were similar. Better perioperative strategies for acute surgical patients with high alcohol intake therefore need to be developed.

Cannabis Use Disorder in the Setting of Primary Total Hip Arthroplasty: Understanding the Epidemiology, Demographic Characteristics, and Inpatient Postoperative Outcomes

INTRODUCTION

Cannabis use is expected to increase in the context of its decriminalization and legalization in several states. The purpose of this study was to report on the epidemiologic and demographic characteristics and inpatient postoperative outcomes of patients with cannabis use disorder (CUD) undergoing primary total hip arthroplasty (THA).

METHODS

The National Inpatient Sample registry was used to identify patients undergoing THA between 2006 and 2015. Patients were stratified into groups with and without CUD. Epidemiology, comorbidity, and outcomes data were comparatively analyzed between these two groups.

RESULTS

A total of 2,838,742 THAs were performed during the study period. The prevalence of CUD significantly increased from 0.10% in 2006 to 0.39% in 2015 (P < 0.0001). Patients with CUD were significantly younger, more likely to be male, had higher rates of Medicaid insurance and were more likely to be non-Hispanic Black and less likely to be non-Hispanic White when compared with the control group. When comparing patients with and without CUD, there was no significant difference in the composite any complication variable and no significant difference in seven of eight individual in-hospital complications assessed, with the exception being higher genitourinary complications in the CUD group. There were no significant differences in discharge disposition or length of stay.

DISCUSSION

Although CUD is significantly associated with various demographic, comorbidity, and hospital characteristics, it is not significantly associated with in-hospital complications, discharge disposition, and length of stay outcomes in the immediate in-hospital, postoperative period. It is critical for clinicians and public health professionals to understand the characteristics and expected inpatient outcomes of this evolving population of patients with CUD undergoing THA, particularly in the context of widespread legalization.

LEVEL OF EVIDENCE

Level III.

The Association of Alcohol Use Disorder with Perioperative Complications following Primary Total Hip Arthroplasty

Purpose

Alcohol use disorder is a leading mental health disorder in the United States. Few studies evaluating the association of alcohol use disorder following primary total hip arthroplasty (THA) have been reported. Therefore, the purpose of this study was to determine whether patients with alcohol use disorder undergoing primary THA have higher rates of: 1) in-hospital lengths of stay (LOS); 2) complications (medical/implant-related); and 3) costs.

Materials and Methods

Using a nationwide claims database from January 1st, 2005 to March 31st, 2014, patients with alcohol use disorder undergoing primary THA were identified and matched to a comparison group according to age, sex, and various comorbidities, resulting in 230,467 patients who were included in the study (n=38,416) and a matched-cohort (n=192,051). Outcomes of interest included comparison of LOS, 90-day medical and 2-year implant-related complications, and costs. A P-value less than 0.002 was considered statistically significant.

Results

Patients with alcohol use disorder had longer in-hospital LOS (4 days vs 3 days; P<0.0001) as well as higher frequency and odds ratio (OR) of 90-day medical (45.94% vs 12.25%; OR, 2.89; P<0.0001) and 2-year implant-related complications (17.71% vs 8.46%; OR, 1.97; P<0.0001). Patients in the study group incurred higher 90-day costs of care ($17,492.63 vs $14,921.88; P<0.0001).

Conclusion

With the growing prevalence of alcohol use disorder in the United States, the current investigation can be utilized to evaluate the need for interventions prior to THA which can potentially minimize the rates of morbidity and mortality within this population.

Alcohol Withdrawal Is Associated With Worse Outcomes in Patients Undergoing Primary Total Knee or Total Hip Arthroplasty

BACKGROUND

Alcohol withdrawal (AW) syndrome is an independent risk factor for postoperative complications. This study aims to evaluate the influence of AW on perioperative outcomes in patients who underwent primary total knee (TKA) or total hip arthroplasty (THA).

METHODS

We used the National Inpatient Sample database to identify patients undergoing TKA/THA from 2003 to 2014. The primary exposure of interest was AW. Multivariable adjusted models were used to evaluate the association of AW with in-hospital medical complications, surgical complications, mortality, cost, and length of stay (LOS) in patients undergoing TKA/THA.

RESULTS

There were 2,971,539 adult hospitalizations for THAs and 6,367,713 hospitalizations for TKAs included in the present study, among which 0.14% of AW for THA patients and 0.10% of AW for TKA patients. Multivariable adjustment analysis suggested that AW was associated with an increased risk of medical complications (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.79-2.42, P < .0001), surgical complications (OR 1.75, 95% CI 1.51-2.03, P < .0001), and had 4.79 times increase of in-hospital mortality, 26% increase of total cost, and 53% increase of LOS in THA procedures. For TKA procedures, AW was also associated with increased risk of medical complications (OR 3.14, 95% CI 2.78-3.56, P < .0001), surgical complications (OR 2.07, 95% CI 1.82-2.34, P < .0001) and 4.24 times increase of in-hospital mortality, 29% increase of total cost, and 58% increase of LOS after multivariable adjustment.

CONCLUSION

AW is associated with increased risk of in-hospital mortality, medical and surgical complications. Proactive surveillance and management of AW may be important in improving outcomes in patients who underwent THA and TKA procedure.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement

OBJECTIVES

Understand the association between social determinants of health and community discharge after elective total joint arthroplasty.

DESIGN

Retrospective cohort design using Optum de-identified electronic health record dataset.

SETTING AND PARTICIPANTS

A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018.

METHODS

Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics.

RESULTS

Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively.

CONCLUSIONS AND IMPLICATIONS

Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis

INTRODUCTION

Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA.

METHODS

We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users.

RESULTS

A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02).

DISCUSSION

Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.

Instability After Total Hip Arthroplasty and the Role of Advanced and Robotic Technology

Instability remains the leading cause of reoperation following total hip arthroplasty (THA). In this article, the risk factors for instability after THA are reviewed, including patient-related characteristics, surgical techniques, positioning of implants, and the role of advanced technology and robotics as a platform that may reduce the incidence of instability.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

A Matched Control Analysis on the Effects of Alcohol Use Disorder After Primary Total Knee Arthroplasty in Medicare Patients

INTRODUCTION

Several studies have found the negative impact of alcohol use disorder (AUD), most notably coagulation derangements. We sought to investigate the effects of AUD after primary total knee arthroplasty (TKA) for (1) postoperative complications, (2) lengths of stay, and (3) costs of care.

METHODS

This was a retrospective database analysis of Medicare patients with AUD undergoing primary TKA performed between 2005 and 2014. Patients with AUD were matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 354,690 TKA patients: 59,126 with AUD and 295,564 without AUD.

RESULTS

Patients with AUD had significantly greater odds ratio (OR) of medical complications, including venous thromboembolism (VTE) within 90 days (OR: 1.41, P < 0.0001) and at 1 year (OR: 1.51, P < 0.0001) and greater 2-year implant-related complications after primary TKA. Furthermore, patients with AUD had significantly longer lengths of stay (4 versus 3 days, P < 0.0001) and incurred a significantly higher episode of care costs ($15,569.76 versus $13,763.06, P < 0.0001).

DISCUSSION

The present study demonstrated a significant association between AUD and the development of VTE. We hope this research will aid in risk stratification and tailoring of VTE chemoprophylaxis and postoperative management in this at-risk group after TKA.

LEVEL OF EVIDENCE

Level III.

Alcohol Abuse and Alcohol Withdrawal Are Associated with Adverse Perioperative Outcomes Following Elective Spine Fusion Surgery

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Alcohol abuse (AA) and alcohol withdrawal (AW), both belonging to alcohol use disorders, bring about vast health consequences, social issues, and financial burden in United States. This study aims to explore the relationship of AA and AW with perioperative outcomes following elective spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Large studies evaluating the outcomes of spine surgery in patients with AA or AW are lacking.

METHODS

We used the National Inpatient Sample (NIS) from 2006 to 2014 to extract records with a primary procedure of spinal fusion surgery. Multivariable regression analysis was used to assess the association of AA and AW with in-hospital mortality, perioperative complications, cost and length of stay (LOS).

RESULTS

Among 3,132,192 patients undergoing elective spinal fusion surgery, the prevalence of AA and AW was 1.14% (35,833) and 0.15% (4623), respectively. Among the AA admissions, 12.90% of patients developed AW. The incidence of overall complications was 6.14%, 10.15%, and 33.73% in patients without AA, with AA and with AW, respectively. After multivariable adjustment, AW was associated with elevated risk of overall complications (odds ratio [OR]: 4.51; 95% confidence interval [CI]: 3.86-5.27), neurologic (OR: 2.58; 95% CI: 1.62-4.12), respiratory (OR: 8.04; 95% CI: 6.62-9.77), cardiac (OR: 3.58; 95% CI: 2.60-4.93), gastrointestinal (OR: 2.31; 95%CI: 1.68-3.17), urinary and renal (OR: 2.68; 95% CI: 2.11-3.39), venous thromboembolism (OR: 3.06; 95% CI: 1.94-4.82), wound-related complications (OR: 3.84; 95% CI: 2.96-4.98) and in-hospital mortality (OR: 5.95; 95% CI: 3.25-10.90). AW was also linked to 40% higher cost and 85% longer LOS.

CONCLUSION

Both AA and AW are associated with adverse outcomes in patients undergoing spinal fusion surgery with more pronounced risks for AW. Aggressive management in perioperative period is required to improve outcomes in these patients.Level of Evidence: 3.

Influence of day of surgery and prediction of LOS > 2 days after fast-track hip and knee replacement

Background and purpose - Enhanced recovery programs have reduced length of stay (LOS) after hip and knee arthroplasty (THA/TKA). Although risk factors disposing to prolonged LOS are well documented, there is limited information on the role of weekday of surgery. This study analyzed the role of weekday of surgery and other potential risk factors for LOS > 2 days.Patients and methods - We included 10,576 unselected consecutive procedures between January 2016 and August 2017 within a multicenter fast-track THA/TKA collaboration with prospective collection of preoperative characteristics. We used multiple regression analysis of potential risk factors for LOS > 2 days followed by construction of a simple risk score from 0 to 15 points based on the calculated odds ratios.Results - Mean LOS was 1.9 (SD 1.8) days, with 80% of patients having surgery from Monday to Wednesday. Of these, 17% (95% CI 16-18) had a LOS > 2 days vs. 19% (CI 17-21) in those operated on Thursday and Friday. Patients were scheduled evenly throughout the week regardless of risk of LOS > 2 days and despite the fact that 38% (CI 35-40) of patients with ≥ 6 points (16% of the total population) had a LOS > 2 days compared with 14% (CI 13-14) in those with < 6 points. In these "high-risk" patients, the fraction with LOS > 2 days increased when having surgery on Thursdays or Fridays (43% CI 38-49) compared with Monday to Wednesday (37% CI 34-39).Interpretation - A detailed preoperative risk assessment may be helpful to plan the weekday of surgery in order to decrease LOS and weekend hospitalization.

Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs

Operations on patients with hemophilia A and B are complex. Studies evaluating postoperative outcomes and costs following total knee arthroplasty (TKA) in patients with hemophilia are limited. A retrospective review of the entire Medicare dataset from 2005 to 2014 was performed. International Classification of Disease 9th revision codes were used to identify patients with hemophilia A and B and they were matched to controls using a 1:1 random matching process based on age, gender, Charlson Comorbidity Index (CCI), and select comorbidity burden. The 90-day preoperative period was evaluated for comorbidities and the 90-day postoperative period was analyzed for outcomes and reimbursements. Logistic regression models were generated to compare outcomes between cases and controls. A total of 4,034 patients with hemophilia were identified as having undergone TKA. About 44.8% were between the ages of 65 and 74 and 62.4% were female. Although the CCI was identical in both cohorts, individual comorbidities not controlled for varied significantly. Medical complications were more frequent among the patients with hemophilia: postoperative bleeding (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2-2.3), deep venous thrombosis (OR: 2.3; 95% CI: 1.8-2.8), pulmonary embolism (OR: 2.9; 95% CI: 2.1-3.9), and blood transfusions (OR: 1.8; 95% CI: 1.6-1.9). Hemophilia was associated with higher odds of periprosthetic infection (1.78 vs. 0.98%, OR: 1.8 95% CI: 1.2-2.7). The 90-day reimbursements were higher for patients with hemophilia (mean: $22,249 vs. $13,017, p < 0.001). Medicare beneficiaries with a diagnosis of hemophilia experience more frequent postoperative complications and incur greater 90-day costs than matched controls following TKA. Surgeons should consider this when optimizing patients for TKA and payors should consider this for risk-adjusting payment models.

Effect of alcohol consumption on patient-reported outcomes in hip arthroscopy: a matched controlled study with minimum 2-year follow-up

INTRODUCTION

There is a paucity of literature examining the effects of alcohol consumption on patient-reported outcomes (PROs) after hip arthroscopy. The purpose of this study was to report 2-year outcomes of hip arthroscopy in patients who consume alcohol compared to patients who abstain.

METHODS

Registry data were prospectively collected and retrospectively reviewed to identify heavy drinkers at the time of primary hip arthroscopy. Patients were matched 1:1 (heavy drinkers:non-drinkers) based on age, sex, BMI, acetabular Outerbridge grade, and capsular treatment. All patients were assessed with 4 validated PROs: mHHS, NAHS, HOS-SSS, and iHOT-12. Pain was estimated with VAS.

RESULTS

42 patients were pair matched in each group (heavy drinkers:non-drinkers). Both groups demonstrated significant improvement for all PROs and VAS. Heavy drinkers reported lesser improvement in HOS-SSS (p = 0.0169), smaller decrease in VAS (p = 0.0157), and lower final scores on iHOT-12 (p = 0.0302), SF-12 mental (p = 0.0086), and VR-12 mental (p = 0.0151). Significantly fewer patients in the heavy-drinking group reached PASS for mHHS (p = 0.0464). Odds of achieving PASS for mHHS was 2.5 times higher for patients who abstain from alcohol. The rates of revision hip arthroscopy and conversion to total hip arthroplasty were not statistically different between groups.

CONCLUSION

While hip arthroscopy may still yield clinical benefit in drinkers, patients who consume heavy amounts of alcohol may ultimately achieve an inferior functional status and should be counselled on drinking cessation to optimise their results.

The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty

BACKGROUND

Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA.

METHODS

A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications.

RESULTS

We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively.

CONCLUSIONS

Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

Preoperative behavioural intervention to reduce drinking before elective orthopaedic surgery: the PRE-OP BIRDS feasibility RCT

BACKGROUND

Heavy alcohol consumption is associated with an increased risk of postoperative complications and extended hospital stay. Alcohol consumption therefore represents a modifiable risk factor for surgical outcomes. Brief behavioural interventions have been shown to be effective in reducing alcohol consumption among increased risk and risky drinkers in other health-care settings and may offer a method of addressing preoperative alcohol consumption.

OBJECTIVES

To investigate the feasibility of introducing a screening process to assess adult preoperative drinking levels and to deliver a brief behavioural intervention adapted for the target population group. To conduct a two-arm (brief behavioural intervention plus standard preoperative care vs. standard preoperative care alone), multicentre, pilot randomised controlled trial to assess the feasibility of proceeding to a definitive trial. To conduct focus groups and a national web-based survey to establish current treatment as usual for alcohol screening and intervention in preoperative assessment.

DESIGN

A single-centre, qualitative, feasibility study was followed by a multicentre, two-arm (brief behavioural intervention vs. treatment as usual), individually randomised controlled pilot trial with an embedded qualitative process evaluation. Focus groups and a quantitative survey were employed to characterise treatment as usual in preoperative assessment.

SETTING

The feasibility study took place at a secondary care hospital in the north-east of England. The pilot trial was conducted at three large secondary care centres in the north-east of England.

PARTICIPANTS

Nine health-care professionals and 15 patients (mean age 70.5 years, 86.7% male) participated in the feasibility study. Eleven health-care professionals and 68 patients (mean age 66.2 years, 80.9% male) participated in the pilot randomised trial. An additional 19 health-care professionals were recruited to one of three focus groups, while 62 completed an electronic survey to characterise treatment as usual.

INTERVENTIONS

The brief behavioural intervention comprised two sessions. The first session, delivered face to face in the preoperative assessment clinic, involved 5 minutes of structured brief advice followed by 15-20 minutes of behaviour change counselling, including goal-setting, problem-solving and identifying sources of social support. The second session, an optional booster, took place approximately 1 week before surgery and offered the opportunity to assess progress and boost self-efficacy.

MAIN OUTCOME MEASURES

Feasibility was assessed using rates of eligibility, recruitment and retention. The progression criteria for a definitive trial were recruitment of ≥ 40% of eligible patients and retention of ≥ 70% at 6-month follow-up. Acceptability was assessed using themes identified in qualitative data.

RESULTS

The initial recruitment of eligible patients was low but improved with the optimisation of recruitment processes. The recruitment of eligible participants to the pilot trial (34%) fell short of the progression criteria but was mitigated by very high retention (96%) at the 6-month follow-up. Multimethod analyses identified the methods as acceptable to the patients and professionals involved and offers recommendations of ways to further improve recruitment.

CONCLUSIONS

The evidence supports the feasibility of a definitive trial to assess the effectiveness of brief behavioural intervention in reducing preoperative alcohol consumption and for secondary outcomes of surgical complications if recommendations for further improvements are adopted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN36257982.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 12. See the National Institute for Health Research Journals Library website for further project information.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Total Joint Arthroplasty Outcomes in Patients With a Previously Failed Toxicology Screen: A Propensity Score-Matched Analysis

BACKGROUND

The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge.

METHODS

A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls.

RESULTS

The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004).

CONCLUSION

These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.

Cannabis Use Does Not Affect Outcomes After Total Knee Arthroplasty

BACKGROUND

The self-reported use of cannabis has increased since its recent legalization in several states. The primary purpose of this study is to report total knee arthroplasty (TKA) outcomes in patients using cannabis.

METHODS

Seventy-one patients who underwent a primary unilateral TKA with minimum 1-year follow-up, who self-reported cannabis use, were retrospectively reviewed. The study period was from January 2014 to February 2018 at a single institution. Patients with a history of opioid consumption, alcohol abuse, tobacco, or illicit drug use were excluded. A matched control was conducted based on age, body mass index, gender, smoking status, and insurance type (surrogate of socioeconomic status) in patients with a unilateral TKA who did not report cannabis use. Outcome measures included Knee Society Scores (KSS), range of motion, Veterans RAND-12 mental and physical component scores. No preoperative differences were noted with these measures. Postoperative complications were recorded and reported.

RESULTS

No difference in length of stay was noted between the users (46.9 hours ± 15.7) and nonusers (49.3 hours ± 20.4) (P = .464). In-hospital total morphine equivalents did not differ between the 2 groups (user = 137 ± 104 mg, nonuser = 146 ± 117 mg, P = .634). Postoperative range of motion did not differ between users (128.4° ± 10.4°) and nonusers (126.9° ± 7.5°) (P = .346). No mean differences in follow-up KSS (user = 180.1 ± 24.9, nonuser = 172.0 ± 33.9, P = .106) or total change (user = 61.7 ± 32.8, nonuser = 62.7 ± 30.7, P = .852) in KSS were noted. Likewise, no significant mean differences in Veterans RAND-12 (mental component scores: user = 54.8 ± 9.3, nonuser = 55.9 ± 8.79, P = .472; physical component scores: user = 48.3 ± 9.9, nonuser = 45.8 ± 10.1, P = .145) scores were demonstrated. There were no differences in readmissions (user = 5, nonuser = 4, P = .730) or reoperations (user = 5, nonuser = 2, P = .238).

CONCLUSION

Cannabis use does not appear to influence (adverse or beneficial) short-term outcomes in patients undergoing a primary TKA. Further studies are warranted to determine the efficacy and safety of cannabis as a constituent of multimodal pain management following TKA before endorsements can be made by orthopedic surgeons.

Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased Hospital Returns for Total Knee Arthroplasty

BACKGROUND

The Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks. We hypothesized that this checklist would improve postoperative metrics that impact costs for total knee arthroplasty (TKA) patients eligible for participation in CJR.

METHODS

Patients undergoing TKA from 2014 to 2018 were retrospectively reviewed. Only patients with eligible participation in CJR were included. Outcome variables including length of stay, disposition, 90-day emergency department visits, and hospital readmissions were explored. Analysis was performed to determine differences in outcomes between CJR participating and non-CJR participating hospitals within the healthcare system.

RESULTS

In total, 2308 TKA patients including 1564 from a CJR participating center and 744 from a non-CJR center were analyzed. There was no significant difference in patient age or gender. Patients at the non-CJR hospital had significantly higher body mass index (P < .001) and American Society of Anesthesiologists scores (P < .001), while those in the CJR network had fewer skilled nursing facility discharges (P = .028) and shorter length of stay (P < .001). However, there was no reduction in 90-day emergency department visits or readmissions.

CONCLUSION

The resources utilized at CJR participating hospitals, including patient optimization checklists, did not effectively alter patient outcomes following discharge. Likely, a checklist alone is insufficient for risk mitigation and detailed optimization protocols for modifiable risk factors must be investigated.

Perioperative Orthopedic Surgical Home: Optimizing Total Joint Arthroplasty Candidates and Preventing Readmission

BACKGROUND

It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities.

METHODS

A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk.

RESULTS

Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P < .05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred.

CONCLUSION

The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Perioperative Management of the Orthopaedic Patient and Alcohol Use, Abuse, and Withdrawal

Alcohol is one of most commonly abused substances in the United States, and it has contributed to a growing epidemic of medical ailments, including cirrhosis, neurologic and psychosocial disorders, impairment to fertility, and cancer. Moreover, acute and chronic alcohol use represent a significant risk factor for orthopaedic injury and postoperative complications. Yet, relatively little is known about the clinical implications of alcohol abuse in common orthopaedic procedures. Acute withdrawal from alcohol is potentially fatal, particularly in the orthopaedic inpatient whose abstinence is mandated by the hospital setting. The aim of this review is to address the screening, diagnostic, and therapeutic tools available to appropriately manage acute alcohol withdrawal in the orthopaedic inpatient. The influence of chronic alcohol consumption on bone metabolism, fracture healing, and surgical fixation will also be reviewed because this information may guide surgical decision making.

Enhanced recovery after cardiac surgery program to improve patient outcomes

This article details the obstacles of implementing a cardiac-specific enhanced recovery after surgery (ERAS) program in a 919-bed not-for-profit community-based health system and the benefits of ERAS programs for different patient populations.

Preoperative Behavioural Intervention versus standard care to Reduce Drinking before elective orthopaedic Surgery (PRE-OP BIRDS): protocol for a multicentre pilot randomised controlled trial

Background

Evidence suggests that increased preoperative alcohol consumption increases the risk of postoperative complications; therefore, a reduction or cessation in alcohol intake before surgery may reduce perioperative risk. Preoperative assessment presents an opportunity to intervene to optimise patients for surgery. This multicentre, two-arm, parallel group, individually randomised controlled trial will investigate whether a definitive trial of a brief behavioural intervention aimed at reducing preoperative alcohol consumption is feasible and acceptable to healthcare professionals responsible for its delivery and the preoperative elective orthopaedic patient population.

Methods

Screening will be conducted by trained healthcare professionals at three hospitals in the North East of England. Eligible patients (those aged 18 or over, listed for elective hip or knee arthroplasty surgery and scoring 5 or more or reporting consumption of six or more units on a single occasion at least weekly on the alcohol screening tool) who enrol in the trial will be randomised on a one-to-one non-blinded basis to either treatment as usual or brief behavioural intervention delivered in the pre-assessment clinic. Patients will be followed up 1–2 days pre-surgery, 1–5 days post-surgery (as an in-patient), 6 weeks post-surgery, and 6 months post intervention. Feasibility will be assessed through rates of screening, eligibility, recruitment, and retention to 6-month follow-up. An embedded qualitative study will explore the acceptability of study methods to patients and staff.

Discussion

This pilot randomised controlled trial will establish the feasibility and acceptability of trial procedures reducing uncertainties ahead of a definitive randomised controlled trial to establish the effectiveness of brief behavioural intervention to reduce alcohol consumption in the preoperative period and the potential impact on perioperative complications.

Trial registration

Reference number ISRCTN36257982

The Association of Delirium with Perioperative Complications in Primary Elective Total Hip Arthroplasty

Background

Our goal was to determine whether postoperative delirium is associated with inpatient complication rates after primary elective total hip arthroplasty (THA).

Methods

Using the National Inpatient Sample, we analyzed records of patients who underwent primary elective THA from 2000 through 2009 to identify patients with delirium (n = 13,551) and without delirium (n = 1,992,971) and to assess major perioperative complications (acute renal failure, death, myocardial infarction, pneumonia, pulmonary embolism, and stroke) and minor perioperative complications (deep vein thrombosis, dislocation, general procedural complication, hematoma, seroma, and wound infection). Patient age, sex, length of hospital stay, and number of comorbidities were assessed. We used multivariate logistic regression to determine the association of delirium with complication rates (significance, p < 0.01).

Results

Patients with delirium were older (mean, 75 ± 0.2 vs. 65 ± 0.1 years), were more likely to be male (56% vs. 52%), had longer hospital stays (mean, 5.7 ± 0.07 vs. 3.8 ± 0.02 days), and had more comorbidities (mean, 2.8 ± 0.03 vs. 1.4 ± 0.01) (all p < 0.001) versus patients without delirium. Patients with delirium were more likely to have major (11% vs. 3%) and minor (17% vs. 7%) perioperative complications versus patients without delirium (both p < 0.001). When controlling for age, sex, and number of comorbidities, delirium was independently associated with major and minor complications (odds ratio, 2.0; 95% confidence interval, 1.7 to 2.3).

Conclusions

Delirium is an independent risk factor for major and minor perioperative complications after primary elective THA.

Hip arthroplasty for osteonecrosis of the femoral head secondary to alcohol abuse

Although the challenges of hip arthroplasty for avascular necrosis (AVN) are known, limited data exist to describe patient demographics and outcomes in the setting of AVN attributed to alcoholism. We retrospectively identified 43 patients (62 hips) who underwent primary hip arthroplasty between 1999 and 2016 for a diagnosis of AVN of the femoral head with a concomitant diagnosis of alcohol abuse and minimum follow-up of 2 years (mean, 8.6 years). The mean age was 51 years, predominantly male (88%), with a high rate of comorbidities. History of cigarette smoking was prevalent (65%). Mean length of stay was 5.3 days, which is prolonged due to a high prevalence of acute postoperative alcohol withdrawal (14.5% of cases). There were 5 early (≤2 years) reoperations (8% of hips) for instability, periprosthetic acetabular fracture and component loosening, heterotopic ossification, superficial infection, and acute periprosthetic infection. There were no additional radiographic failures. The mean postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement was 97.8 ± 7.8, indicative of excellent outcomes at final follow-up of 2 to 18 years. Early risks associated with hip replacement surgery must be communicated to the predominantly young male subgroup of patients with AVN attributed to alcoholism, but these patients may achieve excellent mid- to long-term outcomes.

Dual Diagnosis and Total Hip Arthroplasty

The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a "dual diagnosis" (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321-e327.].

Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1)

In the face of escalating costs and variations in quality of care, bundled payment models for total joint arthroplasty procedures are becoming increasingly common, both through the Centers for Medicare & Medicaid Services and private payer organizations. The effective implementation of these payment models requires cooperation between multiple service providers to ensure economic viability without deterioration in care quality. This article introduces a stepwise model for the financial analysis of bundled contracts for use in negotiations between hospitals and private payer organizations.

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

METHODS

The Medicare standard analytical files were queried using International Classification of Disease codes between 2005 and 2014 to identify patients undergoing primary TKA. Patients with a diagnosis of hypothyroidism were matched by age and gender on a 1:1 ratio. Ninety-day postoperative complication rates, day of surgery, and 90-day global period charges and reimbursements were compared between matched cohorts.

RESULTS

A total of 2,369,594 primary TKAs were identified between 2005 and 2014. After age and gender matching, each cohort consisted of 98,555 patients. Hypothyroidism was associated with greater odds of postoperative complications compared to matched controls (odds ratio 1.367, 95% confidence interval 1.322-1.413). The 90-day incidence of multiple postoperative medical and surgical complications, including periprosthetic joint infection, was higher among patients with hypothyroidism. Day of surgery and 90-day episode of care costs were significantly higher in the hypothyroidism cohort.

CONCLUSION

This study demonstrated an increased risk of multiple postoperative complications and higher costs among patients with hypothyroidism following primary TKA. Surgeons should counsel patients on these findings and seek preoperative optimization strategies to reduce these risks and lower costs in this patient population.

Risk of Complications After THA Increases Among Patients Who Are Coinfected With HIV and Hepatitis C

BACKGROUND

Individuals coinfected with both hepatitis C virus (HCV) and HIV represent a unique and growing population of patients undergoing orthopaedic surgical procedures. Data regarding complications for HCV monoinfection or HIV monoinfection are robust, but there are no data available, to our knowledge, on patients who have both HCV and HIV infections.

QUESTIONS/PURPOSES

We sought to determine whether patients with coinfection differed in terms of baseline demographics and comorbidity burden as compared with patients without coinfection and whether these potential differences were translated into varying levels of postoperative complications, mortality, and hospital readmission risk. Specifically, we asked: (1) Are there demonstrable differences in baseline demographic variables between patients infected with HCV and HIV and those who do not have those infections (age, sex, race, and insurance status)? (2) Do patients with HCV and HIV infection differ from patients without those infections in terms of other medical comorbidities? (3) Do patients with HCV/HIV coinfection have a higher incidence of early postoperative complications and mortality than patients without coinfection? (4) Is the frequency of readmission greater for patients with HCV/HIV coinfection than those without?

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing THA between 2010 and 2014. The SPARCS database is particularly useful because it captures 100% of all New York State inpatient admissions while providing detailed demographic and comorbidity data for a large, heterogeneous patient population with long-term followup. Patients were stratified into four groups based on HCV/HIV status: control patients without disease, HCV monoinfection, HIV monoinfection, and coinfection. We sought to determine whether patients coinfected with HCV and HIV would differ in terms of demographics from patients without those infections and whether patients with HCV and HIV would have a greater risk of complications, longer length of stay, and hospital readmission. A total of 80,722 patients underwent THA between 2010 and 2014. A total of 98.55% (79,554 of 80,722) of patients did not have either HCV or HIV, 0.66% (530 of 80,722) had HCV monoinfection, 0.66% (534 of 80,722) HIV monoinfection, and 0.13% (104 of 80,722) were coinfected with both HCV and HIV. Multivariate analysis was performed controlling for age, sex, insurance, residency status, diagnosis, and comorbidities to allow for an equal comparison between groups.

RESULTS

Patients with coinfection were more likely to be younger, male (odds ratio [OR], 2.90; 95% confidence interval [CI], 2.20-3.13; p < 0.001), insured by Medicaid (OR, 6.43; 4.41-7.55; p < 0.001), have a history of avascular necrosis (OR, 8.76; 7.20-9.53; p < 0.001), and to be homeless (OR, 6.95; 5.31-7.28; p < 0.001) as compared with patients without HIV or HCV. Additionally, patients with coinfection had the highest proportion of alcohol abuse, drug abuse, and tobacco use along with a high proportion of psychiatric disorders, including depression. HCV and HIV coinfection were independent risk factors for increased length of stay (OR, 1.97; 95% CI, 1.29-3.01; p < 0.001), having two or more in-hospital complications (OR, 1.64; 1.01-2.67; p < 0.001), and 90-day readmission rates (OR, 2.97; 1.86-4.77; p < 0.001).

CONCLUSIONS

As the prevalence of HCV and HIV coinfectivity continues to increase, orthopaedic surgeons will encounter a greater number of these patients. Awareness of the demographic and socioeconomic factors leading to increased complications after THA will allow physicians to consider interventions such as in-hospital psychiatric counseling, advanced discharge planning, and coordination with social work and collaboration with HCV/HIV infectious disease specialists to improve patient health status to improve outcomes and reduce costs.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Season of the year influences infection rates following total hip arthroplasty

AIM

To research the influence of season of the year on periprosthetic joint infections.

METHODS

We conducted a retrospective review of the entire Medicare files from 2005 to 2014. Seasons were classified as spring, summer, fall or winter. Regional variations were accounted for by dividing patients into four geographic regions as per the United States Census Bureau (Northeast, Midwest, West and South). Acute postoperative infection and deep periprosthetic infections within 90 d after surgery were tracked.

RESULTS

In all regions, winter had the highest incidence of periprosthetic infections (mean 0.98%, SD 0.1%) and was significantly higher than other seasons in the Midwest, South and West (P < 0.05 for all) but not the Northeast (P = 0.358). Acute postoperative infection rates were more frequent in the summer and were significantly affected by season of the year in the West.

CONCLUSION

Season of the year is a risk factor for periprosthetic joint infection following total hip arthroplasty (THA). Understanding the influence of season on outcomes following THA is essential when risk-stratifying patients to optimize outcomes and reduce episode of care costs.