Does Marital Status Impact Outcomes After Total Knee Arthroplasty?

Patient Designation Prior to Total Knee Arthroplasty: How Can Preoperative Variables Impact Postoperative Status?

BACKGROUND

Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively.

METHODS

We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion.

RESULTS

Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion.

CONCLUSION

Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.

Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update

INTRODUCTION

Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids.

AREAS COVERED

This is a narrative review of the literature.

EXPERT OPINION

Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.

Derivation of a clinical prediction rule for chronic post-surgical pain after total knee arthroplasty considering biopsychosocial factors: A prospective cohort study

BACKGROUND

Biopsychosocial factors are involved in the occurrence of chronic post-surgical pain (CPSP) after total knee arthroplasty (TKA). The purpose of this study was to develop a clinical prediction rule (CPR) that considers biopsychosocial factors to predict which patients are more likely to develop CPSP after TKA.

METHODS

CPSP after TKA was dichotomized into CPSP and non-CPSP groups using the Likert scale and Minimal clinically important difference, and binomial logistic regression analysis was performed. Cut-off values were then calculated using the extracted factors and dichotomized variables. The cut-off values and dichotomized variables were then used to derive a CPR that discriminates between groups with and without CPSP.

RESULTS

Seventy-one TKA patients were included in the study. Binomial logistic regression analysis revealed that Central Sensitization Inventory (CSI) and Pittsburgh Sleep Quality Index (PSQI) were associated with CPSP. The cut-off values for CSI and PSQI were 26 and 7, respectively. The CPSP scale was created using the cut-off values of CSI and PSQI, with a score of 0 for being below the cut-off values of both CSI and PSQI, 1 for being above the cut-off values of either CSI or PSQI, and 2 for being above the cut-off values of both CSI and PSQI. Furthermore, the area under the curve (AUC) for CPR created by the presence of CPSP and using the CPSP scale was significant (AUC = 0.766; P = 0.001).

CONCLUSION

The combination of the two tests, CSI and PSQI, suggested the possibility of predicting CPSP after TKA.

Yoga is effective in treating symptoms of Gulf War illness: A randomized clinical trial

Many Veterans of the 1990-1991 Gulf War report symptoms of Gulf War Illness, a condition involving numerous chronic symptoms including pain, fatigue, and mood/cognition symptoms. Little is known about this condition's etiology and treatment. This study reports outcomes from a randomized controlled single-blind trial comparing yoga to cognitive behavioral therapy for chronic pain and other symptoms of Gulf War Illness. Participants were Veterans with symptoms of GWI: chronic pain, fatigue and cognition-mood symptoms. Seventy-five Veterans were randomized to treatment via selection of envelopes from a bag (39 yoga, 36 cognitive behavioral therapy), which consisted of ten weekly group sessions. The primary outcomes of pain severity and interference (Brief Pain Inventory- Short Form) improved in the yoga condition (Cohen's d = .35, p = 0.002 and d = 0.69, p < 0.001, respectively) but not in the CBT condition (d = 0.10, p = 0.59 and d = 0.25 p = 0.23). However, the differences between groups were not statistically significant (d = 0.25, p = 0.25; d = 0.43, p = 0.076), though the difference in an a-priori-defined experimental outcome variable which combines these two variables into a total pain variable (d = 0.47, p = 0.047) was significant. Fatigue, as indicated by a measure of functional exercise capacity (6-min walk test) was reduced significantly more in the yoga group than in the CBT group (between-group d = .27, p = 0.044). Other secondary outcomes of depression, wellbeing, and self-reported autonomic nervous system symptoms did not differ between groups. No adverse events due to treatment were reported. Yoga may be an effective treatment for core Gulf War Illness symptoms of pain and fatigue, making it one of few treatments with empirical support for GWI. Results support further evaluation of yoga for treating veterans with Gulf War Illness. CLINICAL TRIAL REGISTRY: clinicaltrials.gov Registration Number NCT02378025.

Race Differences in Post-Acute Physical Therapy Utilization and Patient-Reported Function after Total Knee Arthroplasty

OBJECTIVE

This observational cohort study included patients of Black and White race and non-Hispanic ethnicity with end-stage knee osteoarthritis who were scheduled to receive total knee arthroplasty (TKA) surgery. We examined whether there are race differences in (1) use of physical therapy (PT) across all post-acute settings and (2) patient-reported physical function following TKA.

METHODS

We collected pre- and post-operative physical function data and post-operative rehabilitation data on 104 Black and White individuals undergoing TKA. Regression analyses and independent samples t-tests were used to explore the predictive value of race on post-operative functional outcome and compare PT utilization within each post-acute setting and across all post-acute rehabilitation settings.

RESULTS

Total PT received was similar between White and Black participants, but there were significant race differences in PT utilization within specific settings. Race did not significantly predict function after TKA, but Black participants had slightly lower self-reported function both before and after surgery than White participants.

CONCLUSION

This is the first study to examine both PT utilization and functional outcomes in a sample of individuals undergoing TKA, and results indicate differences in where post-operative PT is received between Black and White patients.

Quantifying Mediators of Racial Disparities in Knee Osteoarthritis Outcome Scores: A Cross-Sectional Analysis

Studies on symptomatic osteoarthritis suggest that Black patients report worse pain and symptoms compared with White patients with osteoarthritis. In this study, we aimed to quantify the relationship among variables such as overall health and socioeconomic status that may contribute to disparities in patient-reported outcomes.

Marital status does not affect the cancer-specific survival of patients with upper tract urothelial carcinoma treated with nephroureterectomy: a propensity score matching study

Background:

The purpose of this study was to investigate the relationship between marital status and the prognosis of patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy (NU).

Methods:

Patients with UTUC who received NU treatment were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. Kaplan–Meier curves and Cox regression were used to analyze the effect of marital status on cancer-specific survival (CSS), and 1:1 propensity score matching (PSM) was performed for married and unmarried patients to explore further the effect of marital status on patients with UTUC.

Results:

Among 1565 eligible patients, 960 (61.3%) were married and 605 (38.7%) were unmarried, of which 146 (9.3%) were divorced/separated, 306 (19.6%) were widowed, and 153 (9.8%) were single. Multivariate Cox regression analysis showed that marital status was not an independent risk factor for patients with UTUC treated with NU. After stratification by grade and SEER stage, multivariate analysis showed that there was no significant difference in 5-year CSS between divorced/separated, widowed, and single patients compared with married patients in different grades and SEER stages. In addition, after PSM analysis, marital status was still not an independent risk factor for patients with UTUC treated with NU.

Conclusion:

For patients with UTUC treated with NU, marital status has no prognostic effect on CSS.

Is social support associated with patient-reported outcomes after joint replacement? A systematic review and meta-analysis

BACKGROUND

Identifying prognostic factors for outcomes after joint replacement could improve the provision of stratified care. This systematic review evaluated whether social support is a prognostic factor for better patient-reported outcomes after total hip replacement (THR) and total knee replacement (TKR).

METHODS

MEDLINE, Embase and PsycINFO were searched from inception to April 2019. Cohort studies evaluating the association between social support and patient-reported outcomes at three months or longer after THR or TKR were included. Data were extracted from study reports. Study quality was assessed using the QUIPS tool. Data were synthesized using meta-analysis and narrative synthesis. The review was registered on PROSPERO (CRD42016041485).

FINDINGS

Searches identified 5,810 articles and 56 studies with data from 119,165 patients were included. In meta-analysis, the presence of social support had a beneficial effect on long-term post-operative WOMAC (mean difference 2.88; 95% CIs 1.30; 4.46) and Oxford Knee Score (0.29; 0.12, 0.45). Social support measured using a validated questionnaire was found to be associated with WOMAC pain (0.04; 0.00, 0.08) but not WOMAC function (-0.01; -0.12, 0.11). The presence of social support had a positive association with some SF-36 subscales but not others. For all outcomes, results of narrative synthesis were inconsistent.

INTERPRETATION

There is evidence that social support is a prognostic factor for some outcomes after joint replacement. Development and evaluation of complex interventions to improve social support and social integration is warranted.

FUNDING

This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

Delayed hospital discharge after total shoulder arthroplasty: why, and who is at risk?

Background

There is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty.

Methods

We retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization.

Results

The most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS.

Conclusions

Prolonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

Do Sociodemographic Factors Relate to Walking Ability in Individuals Who Underwent Total Knee Arthroplasty?

BACKGROUND AND PURPOSE

Knee osteoarthritis is one of the most common health problems in older adults and total knee arthroplasty (TKA) is able to improve walking ability in these individuals. There have been few studies investigating whether sociodemographic factors influence walking ability after TKA. The aim of this study was to examine which sociodemographic factors relate to walking ability in Japanese older adults following TKA during the acute stage of recovery.

METHODS

This prospective cohort study included 388 participants, from a multicenter database, who underwent TKA. The Timed Up and Go test 2 weeks after TKA was the dependent variable. Sociodemographic factors including age, sex, body mass index, marital status, and academic qualification were independent variables. In addition, type of surgery and severity of osteoarthritis were measured as confounding variables. A hierarchical multiple regression analysis was used to predict the factors that have the greatest influence on walking ability. Models were examined with and without confounding factors.

RESULTS AND DISCUSSION

In the final regression model, older age, conventional TKA approaches, increased severity of Kellgren-Lawrence grade, and women were associated with longer Timed Up and Go time. Academic qualification and marital status were not related to walking ability.

CONCLUSIONS

Our results suggest that age, type of surgery, severity of osteoarthritis, and sex are related to Timed Up and Go time during the acute stage following TKA and need to be assessed.

Tobacco Smoking Independently Predicts Lower Patient-Reported Outcomes: New Insights on a Forgotten Epidemic

BACKGROUND

Although smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA).

METHODS

A retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed.

RESULTS

There were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052).

CONCLUSION

Tobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation.

Payer type does not impact patient-reported outcomes after primary total knee arthroplasty

Background

There is a paucity of literature assessing whether payer type has an impact on postoperative patient-reported outcomes (PROs) after total knee arthroplasty (TKA). The aim of this study was to comparatively evaluate TKA PROs among patients with commercial and Medicare insurance.

Methods

We conducted a single-center, retrospective review of patients operated between January 2017 and March 2018. Knee Disability and Osteoarthritis Outcome Score Junior (KOOS-Jr) and Veterans RAND 12 Health Survey (VR-12) Physical Component (VR-12 PCS) and Mental Component (VR-12 MCS) PRO scores were collected prospectively at baseline and 12 weeks postoperatively via an electronic patient rehabilitation application. Univariable and multivariable linear regressions were utilized to assess the effects of patient insurance type on PRO.

Results

In total, 193 TKA candidates had commercial (n = 91) or Medicare (n = 102) as their primary payer type. Demographic variables including age, gender, body mass index, and race varied significantly between the cohorts (P < .05). Length of stay and discharge disposition also varied significantly (P < .05). When compared with commercial payers, Medicare beneficiaries demonstrated a 4.13 ± 2.06 increase in Knee Disability and Osteoarthritis Outcome Score JR. scores at baseline (P < .05). However, after adjusting for patient-specific demographic and perioperative variables, all PROs recorded in this study were similar between the 2 payer groups at baseline and 12 weeks postoperatively (P > .05). Furthermore, ΔPRO scores from baseline to 12 weeks were also similar (P > .05).

Conclusions

After adjusting for patient-specific variables, PROs are similar at baseline and 12 weeks postoperatively between commercial and Medicare cohorts. For TKA candidates with similar baseline demographics, surgeons can expect similar perioperative PROs regardless of insurance type.

Socio-demographic factors impact time to discharge following total knee arthroplasty

AIM

To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA).

METHODS

The study included primary TKA’s performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS.

RESULTS

Eight hundred and six consecutive primary SSP TKA’s were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA’s performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient’s living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery.

CONCLUSION

The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Patients With Valgus Alignment and Patients With Varus Alignment Are Not Mere Opposites of Each Other Prior to Total Knee Arthroplasty

Although it is common practice to assess alignment prior to total knee arthroplasty, preoperative knee alignment and its effect on patient-reported outcomes (PROs) postoperatively has not been well studied. The purpose of this retrospective study was to determine if there are differences in PROs between patients with valgus deformities and patients with varus deformities. Further, this study assessed the baseline differences between these 2 groups preoperatively. Patients were placed into either the valgus or the varus group. Data collected included age, sex, race, height, weight, body mass index, knee alignment, Kellgren-Lawrence grade, and 2 PRO measures. Patient-reported outcomes were assessed preoperatively and at 5 scheduled follow-up visits during the first year postoperatively. The authors found that a higher percentage of female patients had a valgus deformity (84.9%). The varus group tended to have a higher body mass index. Radiographs revealed differences in tibia and femur deformities. The overall deformity was less in patients with a valgus deformity than in patients with a varus deformity (mean, 6.6° [SD, 4.4°] vs 8.6° [SD, 4.8°], P=.010). Preoperative Knee injury and Osteoarthritis Outcome Score symptoms were significantly worse in the valgus group (P=.033). After adjusting for the significant baseline differences, all patients reported improved PROs during the postoperative period (P<.0001). Preoperatively, patients with valgus deformities and patients with varus deformities do not appear to be mere opposites of one another. The groups differed by sex, Knee injury and Osteoarthritis Outcome Score symptoms, and tibia, fibula, and overall deformity. Postoperatively, there were no significant differences in PROs during and up to 1 year. [Orthopedics. 2018; 41(6):e783-e788.].

[Total knee arthroplasty in the elderly]

BACKGROUND

The number of total knee arthroplasties in elderly patients is increasing in accordance with the demographic shift in the population.

OBJECTIVE

Analysis of the special situation in the elderly, conservative treatment options, perioperative risk factors, preoperative preparation, special intraoperative features and outcome.

METHODS

Analysis of currently available scientific data and presentation of own scientific study results.

RESULTS

Total knee arthroplasty in elderly patients is related to an increased perioperative risk of complications. A thorough interdisciplinary preparation is required to reduce risk factors. Ligament stability of the knee does not correlate with age. The postoperative outcome after total knee arthroplasty in elderly patients is decisively influenced by the preoperative function and psychosocial parameters.

CONCLUSION

Total knee arthroplasty in elderly patients is particularly challenging for orthopedic surgeons and requires close interdisciplinary cooperation.