Early Postoperative Outcomes of Primary Total Knee Arthroplasty After Solid Organ Transplantation in the United States, 1998-2011

Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review

Solid organ transplants (SOT) have evolved into life-saving interventions for end-stage diseases affecting vital organs. Advances in transplantation techniques, donor selection, and immunosuppressive therapies have enhanced outcomes, leading to a growing demand for SOT. Patients with a solid organ transplant are living long enough to develop the same pathologies which are indicated for joint replacement surgery in the general population. SOT patients who undergo a total hip, knee, or shoulder arthroplasty do similarly in the context of clinical outcomes and implant survival when compared to the general population. These immunosuppressed patients tend to have higher complication rates in the short-term following surgery. Prudent management of these patients in the short-term may be necessary, but patients can expect to do well otherwise.

Timing of Renal Transplant Prior to Total Knee Arthroplasty Impacts 90-Day Postoperative Outcomes

BACKGROUND

Renal transplant (RT) patients are at increased risk for complications after total knee arthroplasty (TKA); however, it is unknown if the time from RT to TKA influences such risks. This study evaluated RT patients undergoing primary TKA at various time intervals after transplant. We hypothesized that increased time between RT and TKA would decrease the risk of complications after TKA.

METHODS

There were 499 RT patients in a national database undergoing subsequent primary TKA from 2010 to 2020. Patients were stratified by intervals of less than 1 year, between 1 and 2 years, and more than 2 years from RT to TKA. Medical complications up to 90 days, readmissions, and 2-year revisions were compared via univariable and multivariable analyses.

RESULTS

Patients who underwent TKA less than 1 year after RT were associated with higher 90-day medical complications when compared to those who underwent TKA 1 to 2 years after RT (odds ratio [OR] 0.4, confidence interval [CI] 0.2 to 0.8, P = .01) and more than 2 years (OR 0.3, CI 0.2 to 0.7, P < .01) after RT. Acute kidney injury and blood transfusion were the most common complications. The TKAs performed 2 years after RT were less likely to have 90-day readmissions when compared to TKAs performed less than 1 year after RT (OR 0.4, CI: 0.2 to 0.9, P < .01). However, time from RT to TKA did not increase the risk of revision at 2 years (P > .30).

CONCLUSIONS

Patients undergoing TKA within 1 year of RT have an increased risk of 90-day postoperative medical complications and readmissions, but the time interval from RT does not appear to affect revision risk. These findings suggest waiting 1 year after RT before proceeding with TKA may be advantageous.

Total Hip and Knee Arthroplasty in Solid Organ Transplant Patients: Perioperative Optimization and Outcomes

The success of renal, liver, cardiac, pulmonary, and other solid organ transplantation (SOT) has resulted in increasing volume of transplant procedures and recipient survivorship. Subsequently, many SOT patients develop end-stage degenerative joint disease and are presenting for total hip or total knee arthroplasty more frequently. Surgeons must be aware of the medical complexities and prepare for the perioperative risks associated with these immunocompromised patients. Preoperative evaluation should be conducted in coordination with transplant specialists to ensure optimization, including appropriate surgical timing and advanced, organ-specific medical assessments. Although often unable to be modified, the transplant patient's antirejection medication regimens should be reviewed with understanding of inherent risks of poor wound healing or acute infection. Despite higher rates of complications, revision surgeries, and mortality compared with the general population, SOT recipients continue to demonstrate markedly improved pain relief, function, and quality of life. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes after total joint arthroplasty in the SOT population.

Total joint arthroplasty following solid organ transplants: complications and mid-term outcomes

PURPOSE

Survival after solid organ transplant (SOT) is improving, and demand for total joint arthroplasty (TJA) among SOT recipients is rising. Outcomes including revision, periprosthetic joint infection, and survivorship based on SOT type are variable. We sought to compare peri-operative complications, implant survivorship, and mortality for patients undergoing TJA following SOT.

METHODS

A retrospective review of the institutional database for primary TJA among SOT recipients from 2000 to 2020 was performed. Revisions, conversion TJA, and patients with multiple organ transplants were excluded. Patients were stratified by transplant organ. Transfusions, 90-day readmissions and emergency department (ED) visits, revisions, and mortality were compared using descriptive statistics and Cox proportional hazard ratios.

RESULTS

A total of 119 total hip arthroplasties (THA) and 63 total knee arthroplasties (TKA) in SOT recipients were studied. Most common SOT was renal (39%), then lung (27%), liver (24%), and heart (10%). TKA postoperative transfusion rates varied by organ (p = 0.037; [heart 0%, liver 9.5%, renal 24.0%, lung 50.0%]). Implant survivorship was 95.6% at one year (95% CI 90.3-98.1) and 92.1% at four years (83.9-96.3). Mortality was 2.9% at one year (95% CI 1.1-7.4) and 23.2% at four years (95% CI 16.1-32.3). After adjusting for procedure, duration from transplant to TJA, age, and Elixhauser Index, lung recipients had higher mortality versus heart (RR 4.39 [95% CI 1.64-15.38]; p = 0.002), kidney (7.98 [3.04-24.61]; p < 0.001), and liver (7.98 [3.04-24.61; p < 0.001) patients.

CONCLUSION

TJA after SOT yields acceptable peri-operative outcomes and implant survivorship, but mortality risk is substantial, especially among lung transplant recipients.

Complications, demographics and hospital stay in organ transplant patients undergoing total hip arthroplasty - A national database study between 2016 and 2019

Background

The purpose of this study was to analyze the post-operative complications following THA in organ transplant patients; and compare the outcome with general population undergoing THA.

Methods and materials

In this retrospective study using the National Inpatient Sample (NIS) database, 813 cases of THA (both primary and revision THA) in organ transplant patients (OT) were reviewed. ICD-10 codes were used to assess post-operative variables including the length of stay, cost of care, medical and surgical complications among OT patients undergoing THA. A comparison of all these variables was made with the non-OT (NOT) control population.

Results

Among 367,894 patients undergoing THR between 2016 and 2019 on NIS database, 813 were OT patients. There was significantly greater proportion of males in the OT group (p < 0.001). Patients in the OT group were also significantly younger (mean age: 61.08 ± 11.95 in OT versus 65.87 ± 11.39 years in NOT; p < 0.001). The OT group had significantly higher prevalence of anemia (p < 0.001), acute renal failure (ARF; p < 0.001), and transfusion rates (p < 0.001). The OT patients also had significantly greater dislocation rates (p = 0.010), wound dehiscence (p = 0.03) and deep surgical-site infections (SSI; p = 0.002). The mean length of hospital stay (3.55 ± 4.89 days in OT vs 2.32 ± 2.52 days in NOT; p < 0.001), cost of care ($82,567.89 ± 74,505.54 vs $66,845.18 ± 47,761.39 for OT and NOT groups, respectively; p < 0.001) and mortality (p = 0.04) were significantly greater in the OT population, as compared to controls.

Conclusion

Organ transplant patients have significantly greater risk for developing post-operative complications like anemia, ARF, need for higher transfusion rates, prosthetic dislocations, wound dehiscence, and deep SSI following THA. The length of stay, total expenditure incurred and mortality were also higher in OT patients undergoing THA.

Revision Total Hip Arthroplasty in Solid Organ Transplant Patients: A Propensity Score-Matched Cohort Study for Aseptic and Infected Revisions

Background

Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total hip arthroplasty (THA) are at an increased risk of postoperative complications. The purpose of this study is to use a large, national database to investigate revision THA (rTHA) outcomes in SOT patients.

Methods

Nationwide Readmissions Database (NRD) from 2010-2018 was used, and ICD-9 and ICD-10 codes were used to identify all patients who underwent rTHA, including those with history of SOT. Propensity score matching (PSM) was used to analyze rTHA outcomes in SOT patients comparted to matched controls. Separate analysis performed for patients undergoing rTHA for prosthetic joint infection (PJI) vs other causes.

Results

A total of 414,756 rTHA, with 1837 of those being performed in SOT patients, were identified. Of these, 65,961 and 276 were performed for PJI in non-SOT and SOT patients, respectively. For non-PJI patients, SOT patients had higher 90-day all-cause readmission rates (24.0% vs 19.4%, P = .03) but lower rate for readmission related to rTHA (6.0% vs 9.2%, P = .03), but no difference readmission for specific rTHA complications, mortality (0.6% vs 1.3%, P = .20), or revision rTHA. Of PJI patients, SOT patients had no difference in overall 90-day readmission (38.6 vs 31.3%, P = .280), readmission for specific rTHA complications, re-revision, or mortality (4.7% vs 6.0%, P = .63).

Conclusions

SOT patients undergoing rTHA for aseptic reasons are higher risk of overall readmission but lower risk of readmission related to rTHA than appropriately matched controls. SOT PJI patients undergoing had similar rates of readmission, mortality, and revision surgery compared to matched non-SOT PJI patients.

Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases

PURPOSE

To investigate (1) healthcare utilization, (2) in-hospital metrics and (3) total in-hospital costs associated with simultaneous versus staged BTKA while evaluating staged BTKA as a single process consisting of two combined episodes.

METHODS

The national readmissions database was reviewed for simultaneous and staged (two primary unilateral TKAs12 months apart) BTKA patients (2016-2017). A total of 19,382 simultaneous BTKAs were identified, and propensity score matched (1:1) to staged BTKA patients (19,382 patients; 38,764 surgeries) based on demographics, comorbidities, and socioeconomic determinants. Outcomes included healthcare utilization [length of stay (LOS) and discharge disposition], in-hospital periprosthetic fractures, non-mechanical complications, and costs. Staged BTKA was evaluated as one process consisting of two episodes. For each staged patient, continuous outcomes were evaluated via the sum of both episodes. Categorical outcomes were added, and percents were expressed relative to total number of surgeries (n = 38,764).

RESULTS

Simultaneous BTKA had longer LOS (5.0 days ± 4.7 vs. 4.5 days ± 3.5; p < 0.001), higher non-home discharge [36.9% (n = 7150/19,382) vs. 13.6% (n = 5451/38,764)], in-hospital periprosthetic fractures [0.13% (26/19,382) vs. 0.08% (31/38,764); p = 0.049], any non-mechanical complication [33.76% (6543/19,382) vs.15.93% (6177/38,764); p < 0.0001], hematoma/seroma formation [0.11% (22/19,382) vs. 0.05% (20/38,764); p = 0.0088], wound disruption [0.08% (16/19,382) vs. 0.04% (16/38,764); p = 0.0454], and any infection [1.13% (219/19,382) vs. 0.50% (194/38,764); p < 0.0001]. Average in-hospital costs for the two staged BTKA episodes combined were $5006 higher than those of simultaneous BTKA ($28,196 ± $18,488 vs. $33,202 ± $15,240; p < 0.001).

CONCLUSION

Simultaneous BTKA had higher healthcare utilization and in-hospital complications than both episodes of staged BTKA combined, with a minimal in-hospital cost savings. Future studies are warranted to further explore patient selection who would benefit from BTKA.

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BACKGROUND

The purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.

METHODS

This was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.

RESULTS

From 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.

CONCLUSION

In this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.

LEVEL OF EVIDENCE

3 (Retrospective cohort study).

Revision total knee arthroplasty outcomes in solid organ transplant Patients, a matched cohort study of aseptic and infected revisions

BACKGROUND

Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total knee arthroplasty (TKA) are at an increased risk of postoperative complications. The purpose of this study is to utilize a large, national database to investigate revision TKA (rTKA) outcomes in SOT patients.

METHODS

This was a retrospective review utilizing the Nationwide Readmissions Database (NRD) and ICD-9 codes to identify patients who underwent rTKA from 2010-2014 with a history of at least one SOT. Propensity-score-matching (PSM) was used to compare rTKA outcomes in SOT patients compared to matched patients without SOT.

RESULTS

A total of 303,867 rTKAs, with 464 of those being performed in SOT patients, were included in the study. Of these, 71,903 and 182 were performed for PJI in non-SOT and SOT patients, respectively. rTKA was performed most frequently in kidney transplant patients (53.0%) followed by liver transplant patients (34.3%). For non-PJI patients, SOT patients had a higher 90-day readmission rate than matched non-SOT rTKA patients (23.2% vs 12.6%, p = 0.006). However, there were no differences in 90-day readmission rates for specific rTKA complications, subsequent revision rTKA, or mortality. Among patients undergoing rTKA for PJI, there was no difference in overall 90-day readmission rate, readmission for specific rTKA complications, subsequent revision rTKA, or mortality.

CONCLUSIONS

While the increased medical comorbidities associated with SOT place patients at increased risk for complications following rTKA, it appears that SOT alone does not do so when patients are matched based on overall medical comorbidity.

Robotic-arm-assisted Knee Arthroplasty Associated With Favorable In-hospital Metrics and Exponentially Rising Adoption Compared With Manual Knee Arthroplasty

BACKGROUND

Technology-assisted knee arthroplasty (KA), including robotic-arm-assisted knee arthroplasty (RA-KA) and computer-assisted (CA-KA) knee arthroplasty, was developed to improve surgical accuracy of implant positioning and alignment, which may influence implant stability, longevity, and functional outcomes. However, despite increased adoption over the past decade; its value is still to be determined.

QUESTIONS/PURPOSE

This study aimed to compare robotic-arm (RA)-KA, CA-KA, and manual (M)-KA regarding (1) in-hospital metrics (length of stay [LOS], discharge disposition, in-hospital complications, and hospitalization-episode costs), (2) characterize annual utilization trends, and (3) future RA-KA and CA-KA utilization projections.

METHODS

National Inpatient Sample was queried for primary KAs (unicompartmental/total; 2008 to 2018). KAs were classified by modality (M-KA/CA-KA/RA-KA) using International Classification of Disease-9/10 codes. A propensity score-matched comparison of LOS, discharge disposition, in-hospital complications (implant-related mechanical or procedure-related nonmechanical complications), and costs was conducted. Trends and projected utilization rates were estimated.

RESULTS

After propensity score matched to their respective M-KA cohorts, RA-KA and CA-KA exhibited shorter LOS (RA-KA versus M-KA: 2.0 ± 1.4 days versus 2.5 ± 1.8 days; P < 0.001; CA-KA versus M-KA: 2.7 ± 1.4 days versus 2.9 ± 1.6 days; P < 0.001) and in-hospital implant-related mechanical complications (P < 0.05, each). RA-KA demonstrated lower nonhome discharge (P < 0.001) and in-hospital procedure-related nonmechanical complications (P = 0.005). RA-KA had lower in-hospital costs ($16,881 ± 7,085 versus $17,320 ± 12,820; P < 0.001), whereas CA-KA exhibited higher costs ($18,411 ± 7,783 versus $17,716 ± 8,451; P < 0.001). RA-KA utilization increased from <0.1% in 2008 to 4.3% in 2018. CA-KA utilization rose temporarily to 6.2% in 2014, then declined to pre-2010 levels in 2018 (4.5%). Projections indicate that RA-KA and CA-KA will represent 49.9% (95% confidence interval, 41.1 to 59.9) and 6.2% (95% confidence interval, 5.3% to 7.2%) of KAs by 2030.

DISCUSSION

RA-KA may provide value through improving in-hospital metrics and mitigating net costs. Similar advantages may not be reliably attainable with CA-RA. Because RA-KA is projected to reach half of all knee arthroplasties done in the United States by 2030, further cost analyses and long-term studies are warranted.

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis

BACKGROUND

There is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population.

METHODS

A systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4).

RESULTS

A total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively).

CONCLUSION

Liver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.

Is there increased value in robotic arm-assisted total hip arthroplasty? : a nationwide outcomes, trends, and projections analysis of 4,699,894 cases

AIMS

The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA.

METHODS

The National Inpatient Sample was queried for primary THAs (2008 to 2017) which were categorized into RA-THA, CA-THA, and M-THA. Past and projected use, demographic characteristics distribution, income, type of insurance, location, and healthcare setting were compared among the three cohorts. In-hospital complications, LOS, discharge disposition, and in-hospital costs were compared between propensity score-matched cohorts of M-THA versus RA-THA and M-THA versus CA-THA to adjust for baseline characteristics and comorbidities.

RESULTS

RA-THA and CA-THA did not exhibit any clinically meaningful reduction in mean LOS (RA-THA 2.2 days (SD 1.4) vs 2.3 days (SD 1.8); p < 0.001, and CA-THA 2.5 days (SD 1.9) vs 2.7 days (SD 2.3); p < 0.001, respectively) compared to their respective propensity score-matched M-THA cohorts. RA-THA, but not CA-THA, had similar non-home discharge rates to M-THA (RA-THA 17.4% vs 18.5%; p = 0.205, and 18.7% vs 24.9%; p < 0.001, respectively). Implant-related mechanical complications were lower in RA-THA (RA-THA 0.5% vs M-THA 3.1%; p < 0.001, and CA-THA 1.2% vs M-THA 2.2%; p < 0.001), which was associated with a significantly lower in-hospital dislocation (RA-THA 0.1% vs M-THA 0.8%; p < 0.001). Both RA-THA and CA-THA demonstrated higher mean higher index in-hospital costs (RA-THA $18,416 (SD $8,048) vs M-THA $17,266 (SD $8,396); p < 0.001, and CA-THA $20,295 (SD $8,975) vs M-THA $18,624 (SD $9,226); p < 0.001, respectively). Projections indicate that 23.9% and 3.2% of all THAs conducted in 2025 will be robotic arm- and computer-assisted, respectively. Projections indicated that RA-THA use may overtake M-THA by 2028 (48.3%) and reach 65.8% of all THAs by 2030.

CONCLUSION

Technology-assisted THA, particularly RA-THA, may provide value by lowering in-hospital early dislocation rates and and other in-hospital metrics compared to M-THA. Higher index-procedure and hospital costs warrant further comprehensive cost analyses to determine the true added value of RA-THA in the episode of care, particularly since we project that one in four THAs in 2025 and two in three THA by 2030 will use RA-THA technology. Cite this article: Bone Joint J 2021;103-B(9):1488-1496.

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair

BACKGROUND

Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients.

METHODS

The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis.

RESULTS

Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1).

CONCLUSION

Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.

Shoulder arthroplasty in solid organ transplant patients: a retrospective, match paired analysis

BACKGROUND

Several studies have evaluated total hip and knee arthroplasty in solid organ transplant (SOT) patients; however, there are limited studies evaluating shoulder arthroplasty in SOT patients. This study compares the complications and functional outcomes of SOT patients undergoing shoulder arthroplasty with a matched control group.

METHODS

The institution's database was retrospectively reviewed for patients with a history of SOT undergoing primary shoulder arthroplasty (with minimum 2-year follow-up) and compared with a control group matched for age, sex, preoperative diagnosis, and surgical procedure. Preoperative and postoperative range of motion and outcome scores, perioperative surgical and medical complications, hospital length of stay, and mortality were compared.

RESULTS

Fifteen patients with previous SOT underwent 19 shoulder arthroplasties. Thirty-four underwent 35 shoulder arthroplasties in the control group. At last follow-up, the SOT group had a significantly worse UCLA score. The SOT group had a significantly worse improvement in UCLA, active elevation, and passive elevation scores in pre- to postoperative scores. There was no difference in length of stay, infection, or surgical complications. Ninety-day readmissions, medically related complications, and required blood transfusion were significantly higher in the SOT group. There was increased mortality in the SOT compared with the control group (death occurred on average 1577 days after arthroplasty).

CONCLUSION

Shoulder arthroplasty in patients with previous SOT appears safe and effective for degenerative shoulder disorders. Patients should be counseled preoperatively that their range of motion and function may not improve as much as their nontransplant cohorts. SOT patients may have increased incidence of postoperative blood transfusions and medically related complications.

Solid Organ Transplant Is Associated With Increased Morbidity and Mortality in Patients Undergoing One or Two-level Anterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied.

METHODS

A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality.

RESULTS

A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p<0.001), higher rate of major medical complications (8.2% vs. 4.5%; OR 1.85, 95% CI 1.45-2.33, p<0.001) and hospital readmission (19.5% vs. 7.5%, OR 2.05, 95% CI 1.74-2.41, p<0.001). In addition, SOT patients had increased mortality within one year of surgery (5.8% vs. 1.3%; OR 3.01, 95% CI 2.26-3.94, p<0.001) compared to non-SOT patients. SOT was not independently associated with SSI (OR 1.25, 95% CI 0.85-1.75, p=0.230), and there was no significant difference in revision rate (0.9% vs. 0.5%; OR 1.54, 95% CI 0.73-2.82, p=0.202) between both groups.

CONCLUSION

SOT is independently associated with longer hospital stay, increased rate of major medical complications, hospital readmission and mortality. Spine surgeons should be aware of the higher rates of morbidity and mortality in these patients and take it into consideration when developing patient-specific treatment plans.

LEVEL OF EVIDENCE

3.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States

BACKGROUND

There is a growing population of patients with history of solid organ transplant (SOT) surgery among total joint patients. Patients with history of SOT have been found to have longer lengths of stay and higher inpatient hospital costs and complications rates after hip and knee arthroplasty. The purpose of this study was to determine whether this is true for shoulder arthroplasty in SOT patients.

METHODS

The Nationwide Inpatient Sample was queried to describe relative demographic, hospital, and clinical characteristics, perioperative complications, length of stay, and total costs for patients with a history of SOT (International Classification of Diseases-9th Edition-Clinical Modificiation V42.0, V42.1, V42.7, V42.83) undergoing shoulder arthroplasty (81.80, 81.88) from 2004 to 2014.

RESULTS

A weighted total of 843 patients (unweighted frequency = 171) and 382,773 patients (unweighted frequency = 77,534) with and without history of SOT, respectively, underwent shoulder arthroplasty. SOT patients were more often younger and more likely to be male, have Medicare, and undergo surgery in a large teaching institution in the Midwest or Northeast (P < .001). SOT patients had higher or similar comorbid disease prevalence for 27 of 29 Elixhauser comorbidities. The risk of any complication was significantly higher among SOT patients (15.5% vs. 9.3%, P = .007). SOT patients experienced inpatient admissions an average 0.27 days longer (P < .001) and $1103 more costly (P = .06) than non-SOT patients.

CONCLUSIONS

Patients with history of SOT undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization.

Lumbar Spine Fusion Surgery in Solid Organ Transplant Recipients Is Associated With Increased Medical Complications and Mortality

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To characterize the outcomes of solid organ transplant (SOT) patients after one- or two-level lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

Over the past decade advances in SOT patients have improved graft survival. As such, this patient population is increasingly eligible for elective surgery such as lumbar fusion procedures to improve mobility and quality of life. However, the outcomes of spine surgery in this population are not well defined.

METHODS

Data from the full 100% Medicare sample between 2005 and 2014 were used for the study. Patients were included if they had an elective one- or two-level lumbar spine fusion and previous history of renal, heart, liver, or lung SOT patients during this period. SOT patients were compared to non-SOT patients with respect to baseline characteristics, 90-day medical complications, 1-year rate of revision surgery, and 1-year mortality.

RESULTS

There were 961 patients in the transplant cohort and 258,342 in the non-SOT cohort. Seventy-seven percent of the SOT patients had prior renal transplant. SOT patients had a longer length of stay (P < 0.001), and a higher 30-day readmission rate compared to non-SOT patients (P =  < 0.001). In addition, SOT patients experienced a 23.8% rate of 90-day postoperative major medical complications and 3.0%, 1-year mortality, significantly larger than respective rates in the control population (P < 0.001). One-year infection, revision surgery rates, and wound dehiscence were not significantly different between the two cohorts.

CONCLUSION

Spine surgery is associated with significant medical complications and 1-year mortality in the SOT population. Although there may be a substantial benefit from lumbar fusion in the SOT population, judicious patient selection is of paramount importance.

LEVEL OF EVIDENCE

3.

National Trends and In-Hospital Outcomes of Patients With Solid Organ Transplant Undergoing Spinal Fusion

STUDY DESIGN

A retrospective analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample.

OBJECTIVE

To examine the demographics and in-hospital outcomes of patients with solid organ transplant (SOT) undergoing spinal fusion on a national level.

SUMMARY OF BACKGROUND DATA

Solid organ transplantation has become more common in recent years and some of these patients undergo spinal fusion surgery. There is, however, little information regarding the trends and outcomes in such patients.

METHODS

Clinical data were derived from the US Nationwide Inpatient Sample between 2000 and 2009. Patients with or without SOT who underwent spinal fusion were identified. Data regarding, patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between patients with or without SOT and analyzed with the use of multivariate logistic regression.

RESULTS

A total of 5984 patients with SOT underwent spinal fusion in the United States during the last decade. From 2000 to 2009, population growth-adjusted incidence of patients with SOT who underwent spinal fusion has increased more than two fold (0.102 in 2000 to 0.236 in 2009, per 100,000, P < 0.001). Comparison between patients with or without SOT showed that patients with SOT had significantly higher overall in-hospital complication rate (22.4% vs. 9.5%) and in-hospital mortality rate (1.3% vs. 0.3%). Graft versus host disease occurred in 0.7% of patients with SOT undergoing spinal fusion. Patients with SOT had a significant higher risk of urinary and renal complications and overall in-hospital complications.

CONCLUSION

During the last decade, the incidence of patients with SOT undergoing spinal fusion has increased in the United States. In-hospital outcomes of patients with SOT undergoing spinal fusion were inferior to those of patients without SOT.

LEVEL OF EVIDENCE

3.

Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All

BACKGROUND

To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models.

METHODS

New York Statewide Planning and Research Cooperative System database for the years 2000-2014.

RESULTS

A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort.

CONCLUSION

Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

Revision Total Hip and Knee Arthroplasties After Solid Organ Transplant

BACKGROUND

As solid organ transplant (SOT) patients' survival improves, the number undergoing total hip (THA) and total knee arthroplasty (TKA) is increasing. Accordingly, the number of revision procedures in this higher-risk group is also increasing. The goals of this study were to identify the most common failure mechanisms, associated complications, clinical outcomes, and patient survivorship of SOT patients after revision THA or TKA.

METHODS

A retrospective review identified 39 revision procedures (30 revision THAs and 9 revision TKAs) completed in 37 SOT patients between 2000 and 2013. The mean age at revision surgery was 62 years with a mean follow-up of 6 years.

RESULTS

The most common failure mode for revision THA was aseptic loosening (10/30, 33%), followed by periprosthetic joint infection (PJI; 7/30, 23%). The most common failure mode for revision TKA was PJI (5/9, 56%). There were 6 re-revision THAs for PJI (3/30; 10%) and instability (3/30; 10%). There were 2 reoperations after revision TKA, both for acute PJI (2/9; 22%). Final Harris Hip Scores significantly (P = .03) improved as did Knee Society Scores (P = .01). Estimated survivorship free from mortality at 5 and 10 years was 71% and 60% after revision THA and 65% and 21% after revision TKA, respectively.

CONCLUSION

Revision THA and TKA after solid organ transplantation carry considerable risk for re-revision, particularly for PJI. Although SOT recipients demonstrate improved clinical function after revision procedures, patient survivorship at mid- to long-term follow-up is low.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications

BACKGROUND

Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA).

METHODS

Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years.

RESULTS

Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%).

CONCLUSION

TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.

Survivorship After Primary Total Hip Arthroplasty in Solid-Organ Transplant Patients

BACKGROUND

Although a growing number of primary total hip arthroplasties (THAs) are being performed on solid-organ transplant (SOT) recipients, long-term patient and implant survivorships have not been well studied in contemporary transplant and arthroplasty practices.

METHODS

A total of 136 THAs (105 patients) with prior SOT were retrospectively reviewed from 2000 to 2013 at mean clinical follow-up of 5 years. The mean age was 59 years, with 39% being females. The most common SOT was renal (56%), followed by liver (24%).

RESULTS

Patient mortality was 3.8% and 13.3% at 2 and 5 years, respectively. There were 9 revisions (6.6%), including 5 (4%) for deep periprosthetic infection. Implant survivorship free of any revision was 95% and 94% at 2 and 5 years, respectively. Transplant type or surgical indication did not significantly impact patient or implant survivorship.

CONCLUSION

Compared with the general population, SOT patients undergoing THA have slightly higher mortality rates at 5 years. Implant survivorship free of revision was slightly lower than the general population, primarily due to an increased risk of periprosthetic joint infection.