1
|
Moffett O, Bloom GB, Barnes CL, Stronach BM, Mears SC, Stambough JB. The Use of General Anesthesia in Revision Joint Arthroplasty. J Arthroplasty 2024; 39:2831-2836. [PMID: 38788812 PMCID: PMC11458356 DOI: 10.1016/j.arth.2024.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers. METHODS We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties and 445 revision total knee arthroplasties) performed over 4 years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions. RESULTS Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day 1 and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only 6 patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80). CONCLUSIONS While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data support the notion that modern GA techniques can be successfully used in revision TJA.
Collapse
Affiliation(s)
- Olivia Moffett
- University of Arkansas for Medical Sciences, College of Medicine
| | - G. Barnes Bloom
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery
| | - C. Lowry Barnes
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery
| | | | - Simon C. Mears
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery
| | | |
Collapse
|
2
|
Cochrane NH, Kim BI, Jiranek WA, Seyler TM, Bolognesi MP, Ryan SP. The Removal of Total Knee Arthroplasty From the Inpatient-Only List has Improved Patient Optimization. J Am Acad Orthop Surg 2024; 32:981-988. [PMID: 38684134 DOI: 10.5435/jaaos-d-22-01132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/11/2023] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION On January 1, 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list, expanding outpatient TKA (oTKA) to include patients with insurance coverage through their programs. These regulatory changes reinforced the need for preoperative optimization to ensure a safe and timely discharge after surgery. This study compared modifiable preoperative optimization metrics in patients who underwent oTKA pre-IPO and post-IPO removal. The authors hypothesized that patients post-IPO removal would demonstrate improvement in the selected categories. METHODS Outpatient TKA in a national database was identified and stratified by surgical year (2015 to 2017 versus 2018 to 2020). Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, hematocrit, sodium, smoking, and body mass index. The percentage of patients who did not meet thresholds pre-IPO and post-IPO removal were compared. RESULTS In total, 2,074 patients underwent oTKA from 2015 to 2017 compared with 46,480 from 2018 to 2020. Patients undergoing oTKA after IPO removal were significantly older (67.0 versus 64.4 years; P < 0.01). A lower percentage of patients in the post-IPO cohort fell outside the threshold for all modifiable risk factors. Results were significant for preoperative sodium (10.7% versus 8.8%; P < 0.01), body mass index (12.4% versus 11.0% P = 0.05), and smoking history (9.9% versus 6.6%; P < 0.01). CONCLUSION Outpatient TKA has increased considerably post-IPO removal. As this regulatory change has allowed older patients with increased comorbidities to undergo oTKA, the need for appropriate preoperative optimization has increased. The current data set demonstrates that surgeons have improved preoperative optimization efforts for select modifiable risk factors.
Collapse
Affiliation(s)
- Niall H Cochrane
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | | | | | | | | | | |
Collapse
|
3
|
Ohmori T, Fraval A, Hozack WJ. Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained. J Arthroplasty 2024; 39:2311-2315. [PMID: 38649063 DOI: 10.1016/j.arth.2024.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND This study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. METHODS A consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). RESULTS The mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. CONCLUSIONS Our study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.
Collapse
Affiliation(s)
- Takaaki Ohmori
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Andrew Fraval
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William J Hozack
- Rothman Institute Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
4
|
Guo S, Zhang J, Li H, Cheng CK, Zhang J. Genetic and Modifiable Risk Factors for Postoperative Complications of Total Joint Arthroplasty: A Genome-Wide Association and Mendelian Randomization Study. Bioengineering (Basel) 2024; 11:797. [PMID: 39199755 PMCID: PMC11351150 DOI: 10.3390/bioengineering11080797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 08/05/2024] [Indexed: 09/01/2024] Open
Abstract
Background: Total joint arthroplasty (TJA) is an orthopedic procedure commonly used to treat damaged joints. Despite the efficacy of TJA, postoperative complications, including aseptic prosthesis loosening and infections, are common. Moreover, the effects of individual genetic susceptibility and modifiable risk factors on these complications are unclear. This study analyzed these effects to enhance patient prognosis and postoperative management. Methods: We conducted an extensive genome-wide association study (GWAS) and Mendelian randomization (MR) study using UK Biobank data. The cohort included 2964 patients with mechanical complications post-TJA, 957 with periprosthetic joint infection (PJI), and a control group of 398,708 individuals. Genetic loci associated with postoperative complications were identified by a GWAS analysis, and the causal relationships of 11 modifiable risk factors with complications were assessed using MR. Results: The GWAS analysis identified nine loci associated with post-TJA complications. Two loci near the PPP1R3B and RBM26 genes were significantly linked to mechanical complications and PJI, respectively. The MR analysis demonstrated that body mass index was positively associated with the risk of mechanical complications (odds ratio [OR]: 1.42; p < 0.001). Higher educational attainment was associated with a decreased risk of mechanical complications (OR: 0.55; p < 0.001) and PJI (OR: 0.43; p = 0.001). Type 2 diabetes was suggestively associated with mechanical complications (OR, 1.18, p = 0.02), and hypertension was suggestively associated with PJI (OR, 1.41, p = 0.008). Other lifestyle factors, including smoking and alcohol consumption, were not causally related to postoperative complications. Conclusions: The genetic loci near PPP1R3B and RBM26 influenced the risk of post-TJA mechanical complications and infections, respectively. The effects of genetic and modifiable risk factors, including body mass index and educational attainment, underscore the need to perform personalized preoperative assessments and the postoperative management of surgical patients. These results indicate that integrating genetic screening and lifestyle interventions into patient care can improve the outcomes of TJA and patient quality of life.
Collapse
Affiliation(s)
- Sijia Guo
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200030, China; (S.G.); (J.Z.)
- Engineering Research Center of Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Jiping Zhang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200030, China; (S.G.); (J.Z.)
- Engineering Research Center of Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Huiwu Li
- Department of Orthopaedics, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, China;
| | - Cheng-Kung Cheng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200030, China; (S.G.); (J.Z.)
- Engineering Research Center of Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Jingwei Zhang
- Department of Orthopaedics, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai 200011, China;
| |
Collapse
|
5
|
Gauthier CW, Bakaes YC, Kern EM, Kung JE, Hopkins JS, Hamilton CA, Bishop BC, March KA, Jackson JB. Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis. J Arthroplasty 2024; 39:1974-1981.e2. [PMID: 38403078 DOI: 10.1016/j.arth.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Chase W Gauthier
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Yianni C Bakaes
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Elizabeth M Kern
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Justin E Kung
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Jeffrey S Hopkins
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Corey A Hamilton
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Braxton C Bishop
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Kyle A March
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - J Benjamin Jackson
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| |
Collapse
|
6
|
Hoyos-Velasco LA, Palacio JC, Stangl WP, Chacón-Castillo CL, Palacio-Aragón V, Pulgarín JP. Risk factors for complications in total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00095-X. [PMID: 38880356 DOI: 10.1016/j.recot.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/04/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Hip arthroplasty represents a significant advancement in the treatment of refractory chronic joint pain, improving quality of life and functionality. The objective of this study is to identify the risk factors associated with local and systemic complications in patients treated with total hip arthroplasty. METHODS Observational, analytical, retrospective cohort study, which included 304 participants treated with total hip replacement. Comparison of variables between two groups was performed; 38 participants in the group with complications and 266 participants in the group without complications. RESULTS The mean age in the complication group was 66 years (SD 18.7) and in the uncomplicated group it was 67,1 years (SD 15.1) (p 0,686). Female sex was observed in 73.3% of the group with complications and 65% in the group without complications. (p 0.292). Risk factors were: hip fracture as an indication for arthroplasty RR 1.33 [95% CI 1.004;1.775 p 0.047], coronary heart disease RR 1.31 [95% CI 1.067;1.616 p 0.010] and surgical bleeding equal to or greater than 400 cc RR 1.11 [95% CI 1.012;1.218 p 0.028]. CONCLUSIONS The risk factors for complications in total hip arthroplasty were: hip fracture as the indication for arthroplasty, coronary artery disease, and surgical bleeding equal to or greater than 400 cc.
Collapse
Affiliation(s)
- L A Hoyos-Velasco
- Servicio de Ortopedia y Traumatología, Grupo de Cirugía Articular de Cadera y Rodilla, Clínica Imbanaco, Cali, Colombia.
| | - J C Palacio
- Servicio de Ortopedia y Traumatología, Grupo de Cirugía Articular de Cadera y Rodilla, Clínica Imbanaco, Cali, Colombia
| | - W P Stangl
- Servicio de Ortopedia y Traumatología, Grupo de Cirugía Articular de Cadera y Rodilla, Clínica Imbanaco, Cali, Colombia
| | - C L Chacón-Castillo
- Medicina General, Servicio de Ortopedia y Traumatología, Clínica Imbanaco, Cali, Colombia
| | - V Palacio-Aragón
- Medicina General, Servicio de Ortopedia y Traumatología, Clínica Imbanaco, Cali, Colombia
| | - J P Pulgarín
- Medicina General, Servicio de Ortopedia y Traumatología, Clínica Imbanaco, Cali, Colombia
| |
Collapse
|
7
|
DeMik DE, Gold PA, Frisch NB, Kerr JM, Courtney PM, Rana AJ. A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care. J Arthroplasty 2024; 39:1125-1130. [PMID: 38336300 DOI: 10.1016/j.arth.2024.01.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.
Collapse
Affiliation(s)
- David E DeMik
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Peter A Gold
- Panorama Orthopedics & Spine Center, Golden, Colorado
| | | | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Chicago, Illinois
| | | | - Adam J Rana
- Maine Medical Partners Orthopedics and Sports Medicine, South Portland, Maine
| |
Collapse
|
8
|
Ashkenazi I, Amzallag N, Factor S, Abadi M, Morgan S, Gold A, Snir N, Warschawski Y. Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis. Clin Orthop Surg 2024; 16:41-48. [PMID: 38304210 PMCID: PMC10825253 DOI: 10.4055/cios23157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/09/2023] [Accepted: 09/09/2023] [Indexed: 02/03/2024] Open
Abstract
Background Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA. Methods We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study. Results The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF. Conclusions The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.
Collapse
Affiliation(s)
- Itay Ashkenazi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Nissan Amzallag
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Shai Factor
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Mohamed Abadi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Samuel Morgan
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Aviram Gold
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Warschawski
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
9
|
Quinlan ND, Hegde V, Bracey DN, Pollet A, Johnson RM, Dennis DA, Jennings JM. Prevalence of Depressive Symptoms in Aseptic Revision Total Knee Arthroplasty Based on the Mode of Failure. Arthroplast Today 2024; 25:101298. [PMID: 38313191 PMCID: PMC10834461 DOI: 10.1016/j.artd.2023.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/18/2023] [Accepted: 11/05/2023] [Indexed: 02/06/2024] Open
Abstract
Background Complications following total knee arthroplasty (TKA) that necessitate revision cause considerable psychological distress and symptoms of depression, which are linked to poorer postoperative outcomes, increased complications, and increased healthcare utilization. We aimed to identify the prevalence of mental health disorders and symptoms preoperatively and postoperatively in patients undergoing aseptic revision TKA and to stratify these patients based on their mechanism of failure. Methods All patients undergoing aseptic revision TKA from 2008 to 2019 with a minimum 1-year follow-up were retrospectively reviewed at a single institution. Patients (n = 394) were grouped based on 7 failure modes previously described. Patients were considered to have depressive symptoms if their Veterans RAND-12 mental component score was below 42. Preoperative and postoperative Veterans RAND-12 mental component scores at the latest follow-up were evaluated. Results Overall comparative prevalence of preoperative to postoperative depressive symptoms was 23.4%-18.8%. By mode of failure are as follows: arthrofibrosis (25.8%-16.7%), aseptic loosening (25.3%-18.9%), extensor mechanism disruption (25%-50%), failed unicompartmental knee arthroplasty (8.6%-14.3%), instability (25.7%-17.1%), osteolysis or polyethylene wear (23.1%-23.1%), and patellar failure (11.8%-23.5%). There was no difference in depressive symptoms among failure modes preoperatively (P = .376) or at the latest postoperative follow-up (P = .175). Conclusions The prevalence of depressive symptoms in revision TKA patients appears to be independent of failure mode. Surgeon awareness and screening for depressive symptoms in this patient population preoperatively with referral for potential treatment may improve early postoperative outcomes.
Collapse
Affiliation(s)
| | - Vishal Hegde
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel N. Bracey
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Aviva Pollet
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
| | | | - Douglas A. Dennis
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
| | - Jason M. Jennings
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| |
Collapse
|
10
|
Gonzalez Gutierrez F, Sun J, Sambandam S. Risk of blood transfusion following total hip arthroplasty: A national database study from 367,894 patients. J Orthop 2023; 46:112-116. [PMID: 37994365 PMCID: PMC10659991 DOI: 10.1016/j.jor.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/24/2023] Open
Abstract
Purpose A growing elderly population in the United States coupled with improvement in surgical techniques have resulted in more elderly individuals undergoing total hip arthroplasty (THA). As such, risk factors associated with increased risk of blood transfusion following THA, which has been linked to various detrimental outcomes, must be better understood. This study aims to identify co-morbidities associated with blood transfusion following THA. Methods Using the Nationwide Inpatient Sample (NIS) database, we selected patients that received a THA from 2016 to 2019 using ICD-10CMP codes. Patients were classified into a "blood transfusion" or "no transfusion" groups and data pertaining to demographics, co-morbidities, and events during hospital stays were compared between the groups. Results Our study dataset included 367,894 patients from the NIS database that underwent a THA from 2016 to 2019. 12,900 (3.5 %) patients received a blood transfusion after their THA and were classified as "blood transfusion group." The remaining 354,994 patients were classified as the "no transfusion group." Elective admission was found to decrease the odds of a blood transfusion following a THA (compared to nonelective THA: odd's ratio 0.283; p value < 0.001). Multivariate analysis demonstrated sickle cell disease, liver cirrhosis, and dialysis exhibited the greatest increase in odds of blood transfusion after a THA by 4.81- (p < 0.001), 3.02- (p < 0.001), and 2.22-fold (p < 0.001), respectively. Looking at patient demographics, male sex increased odds of postoperative transfusion by 1.99 (p < 0.001) while Caucasian ethnicity decreased odds of postoperative transfusion by 0.65 (p < 0.001). Conclusion Blood transfusion has a low occurrence in the early post-operative period following THA (3.6 % of patients). Sickle cell disease, liver cirrhosis, dialysis, SLE, and heart pathologies were the comorbidities found to be most significantly associated with an increased risk of blood transfusion after a THA. Additionally, both mortality and non-elective admissions were significantly more prevalent in the "blood transfusion" group.
Collapse
Affiliation(s)
| | - Joshua Sun
- University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Senthil Sambandam
- University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| |
Collapse
|
11
|
Harris AB, Narain S, Gu A, Best M, Thakkar S, Khanuja H, Sterling R. Data-driven preoperative hemoglobin thresholds in patients undergoing Bilateral simultaneous total Knee arthroplasty are similar to patients undergoing unilateral total Knee arthroplasty. Knee 2023; 42:258-263. [PMID: 37105013 DOI: 10.1016/j.knee.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/21/2023] [Accepted: 03/02/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Preoperative anemia is a risk factor for transfusions and complications following total knee arthroplasty (TKA). Bilateral TKA (bTKA) is more extensive compared to unilateral TKA (uTKA) and a higher preoperative hemoglobin threshold may be warranted. We hypothesized that the optimal hemoglobin cutoff value which predicts the need for postoperative transfusion would be higher for bTKA than uTKA. METHODS We conducted a case control study using a national database and identified patients undergoing primary TKA from 2010-2020. 1:1, nearest-neighbor propensity-score matching was used to create a cohort of patients undergoing uTKA matched with patients undergoing bTKA based on age, gender, Charlston Comorbidity Index (CCI), and American Society of Anesthesiology (ASA) classification. After 2015, NSQIP discontinued collection of the variables MI, angina, and hemiplegia. Thus, the accuracy of CCI, which was used as a matching variable, will be less accurate after 2015. To explore this limitation further, a sensitivity analysis was performed excluding data after 2015 and there was no change in the significance of our primary outcomes. Hemoglobin thresholds which maximally predict postoperative transfusion risk and 30-day complications were identified using Youden's index. Significance was considered if 95% CI's were non-overlapping. RESULTS 9,891 patients were included in each of the bTKA and uTKA cohorts with successful 1:1 matching (p > 0.05 for all criteria). 3.216 (16 %) of patients received a transfusion in the postoperative period. Hemoglobin values which predict postoperative transfusions were not significantly different between uTKA and bTKA for both female and male groups. In females, the preoperative hemoglobin threshold was 12.8 g/dL (95 % CI: 12.2-13.3) in patients undergoing bTKA and 12.7 g/dL (95 % CI: 12.2 - 13.2) in uTKA. In males, the threshold was 13.9 (95 % CI: 13.7-14.2) in patients undergoing bTKA and 13.1 g/dL (95 % CI: 12.5-13.8) in patients undergoing uTKA. CONCLUSIONS Preoperative hemoglobin values which maximally predict postoperative transfusion risk following uTKA and bTKA are similar without significant differences.
Collapse
Affiliation(s)
- Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, United States.
| | - Sasha Narain
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Alex Gu
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, United States
| | - Matthew Best
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, United States
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, United States
| | - Harpal Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, United States
| | - Robert Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, United States
| |
Collapse
|
12
|
Binkley N, Nickel B, Anderson PA. Periprosthetic fractures: an unrecognized osteoporosis crisis. Osteoporos Int 2023; 34:1055-1064. [PMID: 36939852 DOI: 10.1007/s00198-023-06695-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/02/2023] [Indexed: 03/21/2023]
Abstract
Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.
Collapse
Affiliation(s)
- Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA.
| | - Brian Nickel
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
| |
Collapse
|
13
|
Cochrane NH, Kim B, Seyler TM, Wellman SS, Bolognesi MP, Ryan SP. The removal of total hip arthroplasty from the inpatient-only list has improved patient selection and expanded optimization efforts. J Arthroplasty 2023:S0883-5403(23)00222-X. [PMID: 36898484 DOI: 10.1016/j.arth.2023.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION On January 1, 2020, the Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the Inpatient-Only (IPO) list. This study evaluated patient demographics and comorbidities, pre-operative optimization efforts, and 30-day outcomes of patients undergoing outpatient THA pre- and post- IPO-removal. The authors hypothesized that patients undergoing THA post-IPO removal would have improved optimization of modifiable risk factors and equivalent 30-day outcomes. METHODS There were 17,063 outpatient THA in a national database stratified by surgery performed pre- (2015 to 2019: 5,239 patients) and post-IPO (2020: 11,824 patients) removal. Demographics, comorbidities, and 30-day outcomes were compared with univariable and multivariable analyses. Pre-operative optimization thresholds were established for the following modifiable risk factors: albumin, creatinine, hematocrit, smoking history, and body mass index. The percentage of patients who fell outside the thresholds in each cohort were compared. RESULTS Patients undergoing outpatient THA post-IPO removal were significantly older; mean age 65 years (range, 18 to 92) vs 62 (range, 18 to 90) years (P<0.01), with a higher percentage of American Society of Anesthesiologists scores 3 and 4 (P<0.01). There was no difference in 30-day readmissions (P=0.57) or reoperations (P=1.00). A significantly lower percentage of patients fell outside the established threshold for albumin (P<0.01) post-IPO removal, and trended towards lower percentages for hematocrit and smoking status. CONCLUSION The removal of THA from the IPO list expanded patient selection for outpatient arthroplasty. Pre-operative optimization is critical to minimize post-operative complications, and the current study demonstrates that 30-day outcomes have not worsened post-IPO removal.
Collapse
Affiliation(s)
- Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Billy Kim
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
14
|
Salimi M, Mirghaderi P, Mosalamiaghili S, Mohammadi A, Salimi A. Joint replacement and human immunodeficiency virus. World J Virol 2023; 12:1-11. [PMID: 36743660 PMCID: PMC9896588 DOI: 10.5501/wjv.v12.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/19/2022] [Accepted: 12/08/2022] [Indexed: 01/18/2023] Open
Abstract
The incidence of human immunodeficiency virus (HIV)-infected cases that need total joint replacement (TJR) is generally rising. On the other hand, modern management of HIV-infected cases has enabled them to achieve longevity while increasing the need for arthroplasty procedures due to the augmented dege-nerative joint disease and fragility fractures, and the risk of osteonecrosis. Although initial investigations on joint replacement in HIV-infected cases showed a high risk of complications, the recent ones reported acceptable outcomes. It is a matter of debate whether HIV-infected cases are at advanced risk for adverse TJR consequences; however, the weak immune profile has been associated with an increased probability of complications. Likewise, surgeons and physicians should be aware of the complication rate after TJR in HIV-infected cases and include an honest discussion of the probable unwelcoming complication with their patients contemplating TJR. Therefore, a fundamental review and understanding of the interaction of HIV and arthroplasty are critical.
Collapse
Affiliation(s)
- Maryam Salimi
- Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz 71936-13311, Iran
| | - Peyman Mirghaderi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran 7138433608, Iran
| | | | - Ali Mohammadi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz 7136587666, Iran
| | - Amirhossein Salimi
- Department of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd 7156893040, Iran
| |
Collapse
|
15
|
Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Cardiovascular Health Disparities. J Am Acad Orthop Surg 2022; 30:1069-1073. [PMID: 35297810 DOI: 10.5435/jaaos-d-21-00920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Cardiovascular disease includes a collection of conditions with 6.7% of American adults having coronary artery disease and 45% having hypertension. Proper management of these conditions is low (<25%). Hypertension is highest among African Americans and is associated with lower socioeconomic status and education level. Heart disease is associated with postoperative complications, such as cardiovascular and cerebrovascular events, pulmonary and coagulopathy complications, and mortality. Underserved communities can be optimized beginning with a thorough preoperative assessment, which includes evaluating for food security, instituting dietary modifications and exercise regimens, and improving cardiovascular health with pharmacologic modalities and specialty care. Nurse navigators can be invaluable for guiding patients through a cardiovascular preoperative optimization pathway.
Collapse
|
16
|
Hunter CW, Deer TR, Jones MR, Chang Chien GC, D’Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
Collapse
Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D’Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | |
Collapse
|
17
|
Chang E, Nickel B, Binkley N, Bernatz J, Krueger D, Winzenried A, Anderson PA. A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116413. [PMID: 35967749 PMCID: PMC9364193 DOI: 10.1177/21514593221116413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Osteoporosis is highly prevalent in elective orthopedic surgery. While preoperative bone health optimization decreases osteoporosis-related complications, there is an unmet need to establish who may benefit from preoperative dual-energy x-ray absorptiometry (DXA). This study assesses a novel, simple screening protocol to identify orthopedic surgical patients for preoperative DXA. Materials/Methods This retrospective cohort study included 628 patients undergoing total knee, hip, or shoulder arthroplasty or thoracolumbar spine fusion. Inclusion criteria were ≥40 years undergoing primary elective surgery. Screening criteria defining who should obtain DXA due to high osteoporosis risk included: female ≥65, male ≥70, fracture history when ≥50 years, or FRAX major osteoporotic fracture risk (without bone mineral density [BMD]-adjustments) ≥8.4%. Osteoporosis was defined by World Health Organization criteria [T-score ≤ -2.5], clinical National Osteoporosis Foundation (NOF) criteria [T-score ≤ -2.5, elevated BMD-adjusted FRAX risk, or prior hip/spine fracture], and modified clinical criteria [NOF criteria simplified to include any non-traumatic prior fracture and FRAX without BMD]. Results The study included 100 TKAs, 100 THAs, 251 TSAs, and 177 spine fusions, average age 65.6 ± 9.8. DXA was available for 209 patients. Screening criteria recommending DXA was met by 362 patients. For those with DXA, screening sensitivity was .96 (CI: .78 to .99) and specificity was .19 (CI: .14 to .25) for identifying T-score osteoporosis. Similar sensitivity of .99 (CI: .91 to .99) and specificity of .61 (CI: .56 to .66) were found for modified clinical osteoporosis. For modified clinical osteoporosis, 192 patients with osteoporosis met criteria (true pos.), 1 patient with osteoporosis did not meet criteria (false neg.), 170 patients without osteoporosis met criteria (false pos.), and 265 patients without osteoporosis did not meet criteria (true neg.). Discussion/Conclusion A simple screening protocol identifies orthopedic surgical candidates at risk of T-score or clinical osteoporosis for preoperative DXA with high sensitivity.
Collapse
Affiliation(s)
- Elliot Chang
- Department of Orthopedics Surgery and
Rehabilitation, University of Wisconsin UWMF Centennial
Bldg, Madison, WI, USA
| | - Brian Nickel
- Department of Orthopedics Surgery and
Rehabilitation, University of Wisconsin UWMF Centennial
Bldg, Madison, WI, USA
| | - Neil Binkley
- University of Wisconsin School of Medicine and
Public Health Osteoporosis Clinical Research Program, Madison, WI, USA
| | - James Bernatz
- Department of Orthopedics Surgery and
Rehabilitation, University of Wisconsin UWMF Centennial
Bldg, Madison, WI, USA
| | - Diane Krueger
- University of Wisconsin School of Medicine and
Public Health Osteoporosis Clinical Research Program, Madison, WI, USA
| | - Alec Winzenried
- Department of Orthopedics Surgery and
Rehabilitation, University of Wisconsin UWMF Centennial
Bldg, Madison, WI, USA
| | - Paul A. Anderson
- Department of Orthopedics Surgery and
Rehabilitation, University of Wisconsin UWMF Centennial
Bldg, Madison, WI, USA
| |
Collapse
|
18
|
DeMik DE, Marinier MC, Glass NA, Elkins JM. Prevalence of Sarcopenia and Sarcopenic Obesity in an Academic Total Joint Arthroplasty Practice. Arthroplast Today 2022; 16:124-129. [PMID: 35677943 PMCID: PMC9168043 DOI: 10.1016/j.artd.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 10/29/2022] Open
|
19
|
What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications? J Arthroplasty 2022; 37:1320-1325.e1. [PMID: 35271979 DOI: 10.1016/j.arth.2022.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA. METHODS Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI. RESULTS A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m2, of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m2 as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed. CONCLUSION Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.
Collapse
|
20
|
Norris AC, Mears SC, Siegel ER, Barnes CL, Stambough JB. Social Needs of Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2022; 37:S416-S421. [PMID: 35197200 PMCID: PMC9454235 DOI: 10.1016/j.arth.2021.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Many patients have unmet social needs that may affect their health care utilization and outcomes. We sought to examine a program to determine the types of social needs facing arthroplasty patients and methods used to address these needs. METHODS We conducted a pilot, retrospective review of our integrated social needs program for total joint arthroplasty (TJA) patients. A 16-question needs assessment was instituted as part of our perioperative protocol between February 1, 2020, to October 1, 2020. We examined the types of social needs in 250 primary TJA patients and a resolution method. We evaluated associations between social needs and demographics and Area Deprivation Index (ADI). Outcome measures were also evaluated, including readmissions, discharge date, and outcome score changes. RESULTS Forty-four (17.6%) patients had a social need. Social needs frequency increased in non-White patients (P ≤ .0001), non-English speakers (P = .0304), younger patients (P = .001), nonmarried patients (P = .0006), unemployed patients (P = .0189), and patients with less health literacy (P = .0215). ADI scores were positively associated with social needs at the national (P = .0006) and state levels (P = .0004). Overall, 75.9% of needs centered around utility payments, employment, prescription costs, education, and transportation. In addition, 64% of the identified needs were resolved through outside referrals. Ninety-day readmissions were significantly higher in patients with social needs (P = .0087). DISCUSSION Overall, 17.6% of patients in our state have social needs before TJA. Factors increasing the risk of social needs include younger age, minority race, single or divorced marital status, unemployment, low health literacy, and higher ADI. The 90-day readmission rate was significantly higher in patients with social needs.
Collapse
Affiliation(s)
- Allen C. Norris
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C. Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Eric R. Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - C. Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jeffrey B. Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR,Address correspondence to: Jeffrey B. Stambough, MD, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| |
Collapse
|
21
|
DeMik DE, Carender CN, Glass NA, Brown TS, Callaghan JJ, Bedard NA. Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty? J Arthroplasty 2022; 37:S63-S69.e1. [PMID: 34511282 DOI: 10.1016/j.arth.2021.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data. RESULTS Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis. CONCLUSION Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.
Collapse
Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | | | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| |
Collapse
|
22
|
Carender CN, Glass NA, DeMik DE, Elkins JM, Brown TS, Bedard NA. Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get? J Arthroplasty 2022; 37:874-879. [PMID: 35124192 DOI: 10.1016/j.arth.2022.01.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029. METHODS Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese. CONCLUSION By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
Collapse
Affiliation(s)
- Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jacob M Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
| | | |
Collapse
|
23
|
Sicat CS, Muthusamy N, Singh V, Davidovitch RI, Slover JD, Schwarzkopf R. Impact of Preoperative Anemia Severity on Primary Total Hip Arthroplasty Outcomes. J Arthroplasty 2022; 37:721-726. [PMID: 34998908 DOI: 10.1016/j.arth.2021.12.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/20/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative anemia (POA) is a significant predictor for adverse outcomes in primary total hip arthroplasty (THA). Current literature has studied POA stratified by severity. This study aims to find a threshold preoperative hemoglobin (Hb) value for increased risk of adverse outcomes in THA. METHODS This is a retrospective analysis of primary THA patients with preoperative Hb values from 2014 to 2021 from an academic orthopedic specialty hospital. Demographics, surgical data, and postoperative outcomes were collected. Patients without preoperative Hb values within the electronic health record system or values acquired >30 days preoperatively were excluded. Patients were grouped based on POA severity using World Health Organization criteria. Secondary analysis using discrete preoperative Hb values was performed. P-values were calculated using analysis of variance/Kruskal-Wallis and chi-squared/Fisher's exact testing with P < .05 considered significant. RESULTS A total of 1347 patients were included: 771 (57.2%) patients with POA and 576 (42.8%) with normal preoperative Hb. In the POA group, 292 (37.9%) were mild, 445 (57.7%) moderate, and 34 (4.4%) severe. Increased length of stay was seen in moderate (3.9 ± 4.3 vs 2.4 ± 2.1, P < .001) and severe (5.0 ± 3.4 vs 2.4 ± 2.1, P < .0001) groups compared to control. The severe group had higher 90-day readmission and revision rates compared to control. Analysis by discrete Hb values showed increased length of stay in Hb values <11 g/dL and a greater proportion of patients with Hb values <12 g/dL were discharged to skilled nursing facilities. CONCLUSION Patients with preoperative Hb <12 g/dL should be assessed for other risk factors that may predispose them to postoperative complications. Further investigation is warranted to develop more robust perioperative management strategies for POA patients undergoing THA. LEVEL III EVIDENCE Retrospective Cohort Study.
Collapse
Affiliation(s)
| | | | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
24
|
DeMik DE, Carender CN, Glass NA, Noiseux NO, Brown TS, Bedard NA. Are Morbidly Obese Patients Equally Benefitting From Care Improvements in Total Hip Arthroplasty? J Arthroplasty 2022; 37:524-529.e1. [PMID: 34883253 DOI: 10.1016/j.arth.2021.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/14/2021] [Accepted: 11/30/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Morbidly obese patients have increased rates of complications following primary total hip arthroplasty (THA) and it is not clear whether improvements in THA care pathways are equally benefitting these patients. The purpose of this study is to assess if reductions in complications have similarly improved for both morbidly obese and non-morbidly obese patients after THA. METHODS Patients undergoing primary THA between 2011 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 and ≥40 kg/m2. Thirty-day rates of infectious complications, readmissions, reoperation, and any complication were assessed. Trends in complications were compared utilizing odds ratios and multivariate analyses. RESULTS In total, 234,334 patients underwent THA and 16,979 (7.8%) had BMI ≥40 kg/m2. Patients with BMI ≥40 kg/m2 were at significantly higher odds for readmission, reoperation, and infectious complications. Odds for any complication were lower for morbidly obese patients in 2011, not different from 2012 to 2014, and higher from 2015 to 2019 compared to lower BMI patients. Odds for any non-transfusion complication were higher for morbidly obese patients and there was no improvement for either group over the study period. There were improvements in rates of readmission and reoperation for patients with BMI <40 kg/m2 and readmission for BMI >40 kg/m2. CONCLUSION Odds for readmission and reoperation for non-morbidly obese patients and readmission for morbidly obese patients improved from 2011 to 2019. Reductions in transfusions are largely responsible for improvements in overall complication rates. Although morbidly obese patients remain at higher risk for complications, there does not appear to be a growing disparity in outcomes between morbidly obese and non-morbidly obese patients.
Collapse
Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | | | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Nicolas O Noiseux
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| |
Collapse
|
25
|
Recent Increases in Outpatient Total Hip Arthroplasty Have Not Increased Early Complications. J Arthroplasty 2022; 37:325-329.e1. [PMID: 34748912 DOI: 10.1016/j.arth.2021.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Outpatient total hip arthroplasty (THA) has increased in recent years. Recent regulatory changes may allow and incentivize outpatient THA in more patients; however, there are concerns regarding safety. The purpose of this study is to assess early complications in outpatient THA compared to longer hospitalization. METHODS We identified patients undergoing primary THA in the National Surgical Quality Improvement Program database between 2015 and 2018. Patients were stratified by length of stay (LOS): 0 days (LOS 0), 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Multivariate analysis was performed. RESULTS In total, 4813 (4%) patients underwent outpatient THA, 84,627 (64%) had LOS of 1-2 days, and 42,293 (32%) had LOS ≥3 days. LOS 0 patients were younger, had lower body mass index, and less medical comorbidities compared to those with postsurgical hospitalization. Any complication was experienced in 3.2% of the LOS 0 group, 5.3% of the LOS 1-2 group, and 15.6% for the LOS ≥3 group (P < .0001). Readmission rates were 1.6%, 2.6%, and 4.7% for the 3 groups, respectively (P < .0001). After controlling for confounding variables, patients with LOS 1-2 days had higher odds for any complication (odds ratio 1.56 [1.32-1.83) and readmission (odds ratio 1.41 [1.12-1.78]) compared to LOS 0 days. Patients with LOS ≥3 days had higher odds for complications compared to LOS 0 or 1-2 days. CONCLUSION Outpatient THA had lower odds for readmission or complications compared to LOS 1-2 days. Despite increased outpatient surgery, many patients had postsurgical hospitalization and, due to patient factors, this remains an integral patient of post-THA care.
Collapse
|
26
|
Kulshrestha V, Sood M, Kumar S, Sood N, Kumar P, Padhi PP. Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study. Clin Orthop Surg 2022; 14:56-68. [PMID: 35251542 PMCID: PMC8858904 DOI: 10.4055/cios20234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022] Open
Abstract
Background With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. Methods This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. Results TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). Conclusions Screening and RM can reduce 90-day complications in patients undergoing TKA.
Collapse
Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Munish Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Santhosh Kumar
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Nikhil Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Pradeep Kumar
- Department of Orthopaedics and Major Rehabilitation Center, Air Force Hospital Kanpur, Kanpur, India
| | - Prashanth P Padhi
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| |
Collapse
|
27
|
Carr CJ, Mears SC, Barnes CL, Stambough JB. Length of Stay After Joint Arthroplasty is Less Than Predicted Using Two Risk Calculators. J Arthroplasty 2021; 36:3073-3077. [PMID: 33933330 PMCID: PMC8380646 DOI: 10.1016/j.arth.2021.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/06/2021] [Accepted: 04/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Predicting the length of stay (LOS) after total joint arthroplasty (TJA) has become more important with their recent removal from inpatient-only designation. The American College of Surgeons (ACS) National Surgical Quality Improvement Program surgical risk calculator and the CMS' diagnosis-related group (DRG) calculator are two common LOS predictors. The aim of our study was to determine how our actual LOS compared with those predicted by both the ACS and DRG. METHODS 99 consecutive TJA (49 hips and 50 knee procedures) were reviewed in Medicare-eligible patients from four fellowship-trained arthroplasty surgeons. Predicted LOS was calculated using the DRG and ACS risk calculators for each patient using demographics, medical histories, and comorbidities. LOS was compared between the predicted and the actual LOS for both total hip arthroplasty (THA) and total knee arthroplasty (TKA) using paired t-tests. RESULTS Actual LOS was shorter in the THA group vs the TKA group (1.29 days vs 1.46 days, P < .05). The actual LOS of patients at our institution was significantly shorter than both DRG and ACS predictions for both THA and TKA (P < .05). In both the THA and TKA patients, the actual LOS (1.29 and 1.46 day) was significantly shorter than the DRG-predicted LOS (2.15 and 2.15 days) which was significantly shorter than the ACS-predicted LOS (2.9 and 3.14 days). CONCLUSION We found the actual LOS was significantly shorter than that predicted by both the DRG and ACS risk calculators. Current risk calculators may not be accurate for contemporary fast-track protocols and newer tools should be developed.
Collapse
Affiliation(s)
- Colin J. Carr
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - Simon C. Mears
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - C. Lowry Barnes
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - Jeffrey B. Stambough
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| |
Collapse
|
28
|
DeMik DE, Carender CN, An Q, Callaghan JJ, Brown TS, Bedard NA. Has Removal From the Inpatient-Only List Increased Complications After Outpatient Total Knee Arthroplasty? J Arthroplasty 2021; 36:2297-2301.e1. [PMID: 33714634 DOI: 10.1016/j.arth.2021.02.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/30/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND On 1/1/2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient-Only (IPO) list. This change allowed expansion of outpatient TKA, potentially to include older, more frail patients at greater risk for perioperative complications. The purpose of this study was to evaluate the impact of removing TKA from the IPO list on early complications. METHODS Patients undergoing TKA in the National Surgical Quality Improvement Program database were identified using CPT code 27447. Only cases with length of stay of zero days were included. Rates of 30-day complications, readmissions, and reoperation were compared before and after TKA was removed from the IPO list (2015-2017 vs 2018). The analysis was performed both with and without propensity score matching. RESULTS 212,313 patients underwent TKA during the study period. 2466 (1.5%) were outpatient TKA in 2015-2017 and 3189 (5.6%) in 2018. After propensity matching, there were 2458 patients in each cohort. Rates of total 30-day complications were significantly lower in 2018 (3.7%) than the years TKA remained on the IPO (4.5%, P = .04). Similarly, rates of any reoperation decreased from 1.2% during 2015-2017 to 0.6% in 2018 (P = .03). There were no significant changes in rates of readmission (2.5% vs 2.2%, P = .5) or wound complications (0.8% vs 0.8%, P = 1.0). CONCLUSION Removal of TKA from the IPO list did not result in an increase in complications or readmissions. These data suggest, despite the regulatory change, surgeons have continued to exercise sound judgment as to what patients can safely undergo outpatient TKA.
Collapse
Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | | | - Qiang An
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| |
Collapse
|
29
|
Johnson NR, Statz JM, Odum SM, Otero JE. Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous? J Arthroplasty 2021; 36:2452-2457. [PMID: 33752925 DOI: 10.1016/j.arth.2021.02.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m2, had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups. RESULTS Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m2, albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality. CONCLUSION Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization. LEVEL OF EVIDENCE Retrospective cohort study, level IV.
Collapse
Affiliation(s)
- Nick R Johnson
- Atrium Health - Department of Orthopaedics, Charlotte, NC; Atrium Health - Musculoskeletal Institute, Charlotte, NC
| | | | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC; Atrium Health - Musculoskeletal Institute, Charlotte, NC
| | - Jesse E Otero
- Atrium Health - Musculoskeletal Institute, Charlotte, NC; OrthoCarolina - Hip & Knee Center, Charlotte, NC
| |
Collapse
|
30
|
DeMik DE, Carender CN, Glass NA, Brown TS, Callaghan JJ, Bedard NA. Are surgeons still performing primary total knee arthroplasty in the morbidly obese? Bone Joint J 2021; 103-B:38-44. [PMID: 34053298 DOI: 10.1302/0301-620x.103b6.bjj-2020-1966.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. METHODS Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m2 and ≥ 40 kg/m2 and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses. RESULTS In total, 314,695 patients underwent TKA and 46,362 (15%) had BMI ≥ 40 kg/m2. The prevalence of morbid obesity among TKA patients did not change greatly, ranging between 14% and 16%. Reoperation rate decreased from 1.16% to 0.96% (odds ratio (OR) 0.81 (95% confidence interval (CI) 0.66 to 0.99)) for patients with BMI < 40 kg/m2, as did rates of readmission (4.46% to 2.87%; OR 0.61 (0.55 to 0.69)). Patients with BMI ≥ 40 kg/m2 also had fewer readmissions over the study period (4.87% to 3.34%; OR 0.64 (0.49 to 0.83)); however, the rate of reoperation did not change (1.37% to 1.41%; OR 0.99 (0.62 to 1.56)). Significant improvements were not observed for infective complications over time for either group; patients with BMI ≥ 40 kg/m2 had increased risk of both deep infection and wound complications compared to non-morbidly obese patients. Rate of any complication decreased for all patients. CONCLUSION The proportion of TKAs in morbidly obese patients has not significantly changed over the past decade. Although readmission rates improved for all patients, reductions in reoperation in non-morbidly obese patients were not experienced by the morbidly obese, resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infective complications in the morbidly obese. Cite this article: Bone Joint J 2021;103-B(6 Supple A):38-44.
Collapse
Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | | | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
31
|
Long G, Chao C, Ming-Sheng T, Ping Y. Low Grip Strength Associated with Clinical Outcomes after Total Hip Arthroplasty - A Prospective Case-Control Study. Orthop Surg 2021; 13:1488-1495. [PMID: 34080763 PMCID: PMC8313166 DOI: 10.1111/os.13007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/14/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess whether low grip strength (GS) is associated with clinical outcomes after total hip arthroplasty (THA). METHODS A prospective case-control study was designed to assess 231 cases of primary THA between January 1, 2015 to May 1, 2018, at an urban tertiary care hospital. Patients were placed into two cohorts based on preoperative GS levels. Low GS in the present study was defined as GS lower than 26 kg for men and 16 kg for women in the dominant hand. Baseline data were prospectively collected and included patient demographics (age, sex, body mass index [BMI]), the surgeon's diagnoses, medical history, length of stay, and American Society of Anaesthesiologists' (ASA) score. Clinical outcomes included surgery- and prosthesis-related variables. The Harris hip score (HHS) and the Short Form Health Survey (SF-12) were completed at the baseline visit and at 1 and 2 years postoperatively in the outpatient department to assess the hip's function and quality of life. Differences in baseline data, length of study (LOS), 90-day postoperative complications, and hospital readmissions were compared. Besides, the correlations between GS and Harris hip score (HHS) and Short Form score (SF-12) were tested. RESULTS A total of 202 participants have completed records for analysis finally. The patients were followed up for an average of 24.8 months postoperatively (24-26 months). Eighty-two patients (40.6%) had low GS before THA. Patients with low GS were more likely to be female, older, fracture of femoral head or neck as the primary cause, albumin <3.5 g/dL, and have a lower BMI, higher ASA score, increased rates of the pressure sore, blood transfusion, and LOS compared to normal GS (all P < 0.05). Also, patients in the low GS cohort showed a statistically significant increased unplanned hospital readmissions and decreased discharge home compared to normal GS (both P < 0.05). There was an increasing rate of complications between the two cohorts, for cardiac complications, pressure sore after THA, respiratory complications, urinary tract infection, stroke, and DVT (all P < 0.05). A partial correlation test by controlling medical comorbidities and demographic factors was used to determine the correlation between GS and HHS. There was a significant correlation between them (r = -0.673; P = 0.002). A similar condition was detected in the correlation between GS and SF-12 (r = 0.645; P = 0.001). CONCLUSIONS Clinicians should be encouraged to include GS assessment in their evaluation of patients who planned to undergo THA in order to optimize the treatment of high-risk individuals.
Collapse
Affiliation(s)
- Gong Long
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical College, Beijing, China
| | - Chen Chao
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Tan Ming-Sheng
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical College, Beijing, China
| | - Yi Ping
- Department of Orthopaedic, China-Japan Friendship Hospital, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical College, Beijing, China
| |
Collapse
|
32
|
Sax OC, Mohamed NS, Pervaiz SS, Douglas SJ, Aboulafia AJ, Delanois RE. The Effect of Modern Antiretroviral Therapy on Complication Rates After Total Hip Arthroplasty. JB JS Open Access 2021; 6:JBJSOA-D-20-00175. [PMID: 34056505 PMCID: PMC8154403 DOI: 10.2106/jbjs.oa.20.00175] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Antiretroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in patients with human immunodeficiency virus (HIV), but additional information on its impact on total hip arthroplasty (THA) complication rates is needed to mitigate risks postoperatively. Therefore, we sought to examine patients with HIV who were and were not taking ART compared with a cohort without HIV in the setting of primary THA with respect to the following outcomes: length of stay, readmissions, and postoperative infection. Methods: A retrospective database review was performed with PearlDiver for patients who underwent THA from 2010 to 2019 (n = 729,101). Patients with HIV who were and were not taking ART were then identified and were matched with patients without HIV at a 1:1:1 ratio based on age, sex, Charlson Comorbidity Index, diabetes, obesity, and tobacco use, resulting in 601 patients in each cohort. Length of stay, 30-day readmissions, and complications at 90 days and 1 year were analyzed. Continuous outcomes were measured via Student t tests, and categorical outcomes were measured via chi-square analyses. Results: Patients with HIV who were and were not taking ART were found to have similar lengths of stay compared with patients without HIV (range, 4.1 to 4.3 days). Readmission rates were slightly higher in patients with HIV who were taking ART at 4.2% (odds ratio [OR], 1.96 [95% confidence interval (CI), 0.99 to 3.87]) and patients with HIV who were not taking ART at 3.5% (OR, 1.63 [95% CI, 0.81 to 3.30]) compared with patients without HIV at 2.1%. Periprosthetic joint infection rates at 1 year were slightly higher among patients with HIV who were not taking ART at 5.3% (OR, 1.41 [95% CI, 0.82 to 2.45]) compared with patients with HIV who were taking ART at 4.2% (OR, 1.09 [95% CI, 0.61 to 1.94]) and patients without HIV at 3.8%. Conclusions: Patients with HIV who are and are not taking ART are approaching normalization to the general population in the setting of THA. It is important to note that, although complications may have been mitigated by modern therapy, extreme care should be taken while clinically evaluating these patients prior to the surgical procedure given the complexity of their clinical status. The findings of this study underscore the utility of ART and patient optimization to reduce risk in this patient population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Oliver C Sax
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Sahir S Pervaiz
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Scott J Douglas
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Albert J Aboulafia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
33
|
Readmission, Complication, and Disposition Calculators in Total Joint Arthroplasty: A Systemic Review. J Arthroplasty 2021; 36:1823-1831. [PMID: 33239241 PMCID: PMC8515596 DOI: 10.1016/j.arth.2020.10.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Predictive tools are useful adjuncts in surgical planning. They help guide patient selection, candidacy for inpatient vs outpatient surgery, and discharge disposition as well as predict the probability of readmissions and complications after total joint arthroplasty (TJA). Surgeons may find it difficult due to significant variation among risk calculators to decide which tool is best suited for a specific patient for optimal decision-based care. Our aim is to perform a systematic review of the literature to determine the existing post-TJA readmission calculators and compare the specific elements that comprise their formula. Second, we intend to evaluate the pros and cons of each calculator. METHODS Using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols protocol, we conducted a systematic search through 3 major databases for publications addressing TJA risk stratification tools for readmission, discharge disposition, and early complications. We excluded those manuscripts that were not comprehensive for hips and knees, did not list discharge, readmission or complication as the primary outcome, or were published outside the North America. RESULTS Ten publications met our criteria and were compared on their sourced data, variable types, and overall algorithm quality. Seven of these were generated with single institution data and 3 from large administrative datasets. Three tools determined readmission risk, 5 calculated discharge disposition, and 2 predicted early complications. Only 4 prediction tools were validated by external studies. Seven studies utilized preoperative data points in their risk equations while 3 utilized intraoperative or postsurgical data to delineate risk. CONCLUSION The extensive variation among TJA risk calculators underscores the need for tools with more individualized stratification capabilities and verification. The transition to outpatient and same-day discharge TJA may preclude or change the need for many of these calculators. Further studies are needed to develop more streamlined risk calculator tools that predict readmission and surgical complications.
Collapse
|
34
|
Risk Adjustment for Episode-of-Care Costs After Total Joint Arthroplasty: What is the Additional Cost of Individual Comorbidities and Demographics? J Am Acad Orthop Surg 2021; 29:345-352. [PMID: 32701687 DOI: 10.5435/jaaos-d-19-00889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/22/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Concerns exist regarding the lack of risk adjustment in alternative payment models for patients who may use more resources in an episode of care. The purpose of this study was to quantify the additional costs associated with individual medical comorbidities and demographic variables. METHODS We reviewed a consecutive series of primary total hip and knee arthroplasty patients at our institution from 2015 to 2016 using claims data from Medicare and a single private insurer. We collected demographic data and medical comorbidities for all patients. To control for confounding variables, we performed a stepwise multivariate regression to determine the independent effect of medical comorbidities and demographics on 90-day episode-of-care costs. RESULTS Six thousand five hundred thirty-seven consecutive patients were identified (4,835 Medicare and 1,702 private payer patients). The mean 90-day episode-of-care cost for Medicare and private payers was $19,555 and $30,020, respectively. Among Medicare patients, comorbidities that significantly increased episode-of-care costs included heart failure ($3,937, P < 0.001), stroke ($2,604, P = 0.002), renal disease ($2,479, P = 0.004), and diabetes ($1,368, P = 0.002). Demographics that significantly increased costs included age ($221 per year, P < 0.001), body mass index (BMI; $106 per point, P < 0.001), and unmarried marital status ($1896, P < 0.001). Among private payer patients, cardiac disease ($4,765, P = 0.001), BMI ($149 per point, P = 0.004) and age ($119 per year, P = 0.002) were associated with increased costs. DISCUSSION Providers participating in alternative payment models should be aware of factors (cardiac history, age, and elevated BMI) associated with increased costs. Further study is needed to determine whether risk adjustment in alternative payment models can prevent problems with access to care for these high-risk patients.
Collapse
|
35
|
Richardson G, Dusik C, Lethbridge L, Dunbar M. Variable effects of obesity on access to total hip and knee arthroplasty. Can J Surg 2021; 64:E84-E90. [PMID: 33599449 PMCID: PMC7955826 DOI: 10.1503/cjs.012719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Obesity is an important comorbidity affecting outcomes after total joint arthroplasty. Consequently, surgeons may delay care of obese patients to first address obesity through different care pathways. The effect of obesity on patient wait times for total joint arthroplasty has not been explored. The purpose of this study was to evaluate the effect of obesity on access to total hip (THA) and knee (TKA) arthroplasty. Methods The study data set was constructed from the Nova Scotia Health Authority’s Horizon Patient Folder system and the Patient Access Registry Nova Scotia. Wait time was measured as days between the decision to treat and date of surgery. Body mass index (BMI) was calculated from a preoperative assessment, and patients were grouped into BMI categories. Multivariate log-linear regression was used to test for statistical differences, controlling for confounding factors. Results We observed longer wait times for TKA with increasing BMI weight class. Patients with BMIs greater than 50 had 34% longer waits than reference weight patients. However, THA recipients showed no statistical difference in wait times across weight categories. Furthermore, there was variability among surgeons in the wait times experienced by patients. Conclusion The finding of longer wait times for TKAs, but not THAs, among patients who were obese was unexpected. This shows the variable wait times for THA and TKA that patients who are obese can experience with different surgeons. It is important to understand the variability in wait times so that efforts to standardize the patient experience can be accomplished.
Collapse
Affiliation(s)
- Glen Richardson
- From the Department of Orthopaedics, Halifax Infirmary, Halifax, NS (Richardson, Dunbar); the Department of Surgery, University of Calgary, Calgary, Alta. (Dusik); and the Department of Surgery, Dalhousie University, Halifax, NS (Lethbridge)
| | - Chris Dusik
- From the Department of Orthopaedics, Halifax Infirmary, Halifax, NS (Richardson, Dunbar); the Department of Surgery, University of Calgary, Calgary, Alta. (Dusik); and the Department of Surgery, Dalhousie University, Halifax, NS (Lethbridge)
| | - Lynn Lethbridge
- From the Department of Orthopaedics, Halifax Infirmary, Halifax, NS (Richardson, Dunbar); the Department of Surgery, University of Calgary, Calgary, Alta. (Dusik); and the Department of Surgery, Dalhousie University, Halifax, NS (Lethbridge)
| | - Michael Dunbar
- From the Department of Orthopaedics, Halifax Infirmary, Halifax, NS (Richardson, Dunbar); the Department of Surgery, University of Calgary, Calgary, Alta. (Dusik); and the Department of Surgery, Dalhousie University, Halifax, NS (Lethbridge)
| |
Collapse
|
36
|
Rajcoomar S, Rajcoomar R, Rafferty M, van der Jagt D, Mokete L, Pietrzak JRT. Good Functional Outcomes and Low Infection Rates in Total Hip Arthroplasty in HIV-Positive Patients, Provided There Is Strict Compliance With Highly Active Antiretroviral Therapy. J Arthroplasty 2021; 36:593-599. [PMID: 32917464 DOI: 10.1016/j.arth.2020.08.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with HIV are more likely to require a total hip arthroplasty (THA) because of an increase in life expectancy and complications with HIV. The purpose of this study is to describe the mid-term outcomes of THA in HIV-positive patients and risk factors for postoperative infections and poor outcomes. METHODS This is a single-center retrospective review of nonhemophiliac HIV-positive patients who underwent THA. We reviewed the short- and mid-term readmission and complication rates. RESULTS Eighty-seven patients underwent 102 THAs. The average age was 58 years (24-73 years). The average body mass index was 31.6 (18-55). The average CD4+ count was 569 cells per cubic millimeter (mm3) (51-1480), and the mean viral load was <40 copies/mL (undetectable-380 000). The mean follow-up time was 6.7 years (24 months- 8.3 years). Four patients had postoperative complications within 30 days. Seven patients had postoperative complications after 30 days; 5 of which had septic loosening of implants and had either not been initiated on or were noncompliant with their highly active antiretroviral therapy. The average postoperative Harris Hip Score was 81 (41-100) and Oxford Hip Score was 43.43 (34-48). There was no correlation the between CD4+ count and viral load with complications. CONCLUSION Low rate of complications and revision is achievable in the HIV-positive, nonhemophilic arthroplasty population contrary to published literature. An important factor ensuring good long-term outcomes in HIV-positive patients undergoing THA was the initiation of highly active antiretroviral therapy before the procedure and ensuring patient compliance with therapy after joint arthroplasty.
Collapse
Affiliation(s)
- Shahil Rajcoomar
- Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| | - Riona Rajcoomar
- Department of Physiotherapy, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| | - Michael Rafferty
- Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| | - Dick van der Jagt
- Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| | - Lipalo Mokete
- Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| | - Jurek R T Pietrzak
- Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Gauteng, South Africa
| |
Collapse
|
37
|
DeMik DE, Carender CN, Glass NA, Callaghan JJ, Bedard NA. Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases. J Arthroplasty 2021; 36:586-592.e1. [PMID: 32917463 PMCID: PMC7445154 DOI: 10.1016/j.arth.2020.08.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA. METHODS Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed. RESULTS In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases. CONCLUSION Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.
Collapse
Affiliation(s)
- David E DeMik
- University of Iowa Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, Iowa 52242
| | - Christopher N Carender
- University of Iowa Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, Iowa 52242
| | - Natalie A Glass
- University of Iowa Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, Iowa 52242
| | - John J Callaghan
- University of Iowa Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, Iowa 52242
| | - Nicholas A Bedard
- University of Iowa Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, Iowa 52242
| |
Collapse
|
38
|
Stambough JB, Hui R, Siegel ER, Edwards PK, Barnes CL, Mears SC. Narcotic Refills and Patient Satisfaction With Pain Control After Total Joint Arthroplasty. J Arthroplasty 2021; 36:454-461. [PMID: 32839063 PMCID: PMC7855659 DOI: 10.1016/j.arth.2020.07.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patient satisfaction has become an important metric for total joint arthroplasty (TJA) used to reimburse hospitals. Despite ubiquitous narcotic use for post-TJA pain control, there is little understanding regarding patient factors associated with obtaining opioid refills and associations with patient satisfaction. METHODS Using our state's mandatory opioid prescription monitoring program, we reviewed preoperative and postoperative narcotic prescriptions filled for 438 consecutive TJA patients. Subjects were divided into 3 groups based on the number of post-TJA narcotic refills obtained (0, 1, or >1), and logistic regression analysis was conducted comparing demographics, surgical factors, and satisfaction with pain control. RESULTS One hundred twenty-five patients (25.8%) did not consume preoperative opioids and received no postoperative refills. Total hip arthroplasty (THA) patients (P = .0004), subjects ≥65 years (P = .0057), and Medicare patients (P = .0058) had significantly higher rates of 0 postdischarge refills. THA recipients had 268% increased odds of not receiving a refill narcotic (adjusted odds ratio = 0.373; 95% confidence interval, 0.224- 0.622). Every 100-morphine milligram equivalent (MME) increase in presurgery use led to a 16% increase in odds of needing >1 opioid refill (adjusted odds ratio = 1.161; 95% confidence interval, 1.085-1.242). Subjects who noted higher satisfaction consumed less overall opioids when receiving a refill (436 vs 1119 MMEs, P = .021). CONCLUSION Subjects who received fewer narcotic prescriptions and overall MMEs demonstrated higher rates of satisfaction with early pain control. Our results are consistent with other studies in showing that increased preoperative narcotic use portends higher rates of postoperative refills. There appears to be a subset of THA patients >65 years of age who may be candidates for opioid-sparing analgesia.
Collapse
Affiliation(s)
- Jeffrey B. Stambough
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - Ryan Hui
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - Eric R. Siegel
- University of Arkansas for Medical Sciences, Department of Biostatistics, 4301 West Markham Street, Slot 515, Little Rock, AR 72205
| | - Paul K. Edwards
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - C. Lowry Barnes
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| | - Simon C. Mears
- University of Arkansas for Medical Sciences, Department of Orthopaedic Surgery, 4301 West Markham Street, Slot 531, Little Rock, AR 72205
| |
Collapse
|
39
|
More Patients Are Being Discharged Home After Total Knee Arthroplasty, However Rates Vary Between Large Databases. J Arthroplasty 2021; 36:173-179. [PMID: 32843255 DOI: 10.1016/j.arth.2020.07.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/12/2020] [Accepted: 07/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications. METHODS Patients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed. RESULTS In total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001). CONCLUSION Patients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.
Collapse
|
40
|
Tourniquetless Total Knee Arthroplasty: History, Controversies, and Technique. J Am Acad Orthop Surg 2021; 29:17-23. [PMID: 33347007 DOI: 10.5435/jaaos-d-20-00321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
We present a literature review with technique for tourniquetless TKA for surgeons interested in transitioning away from the tourniquet. Tourniquet use provides a bloodless field and improved visualization with decreased intraoperative blood loss, but the arguments for tourniquet use of improved cement fixation and decreased overall blood loss have not been supported by the literature. Regarding recovery, tourniquetless TKA has demonstrated less postoperative pain and improved knee function. There is also the potential for patient harm with tourniquet use. The process of tourniquetless TKA begins preoperatively with anemia screening and treatment. Tranexamic acid decreases the overall blood loss and blood transfusion risk. We recommend preemptive analgesia. The surgery is performed with the knee flexed for a near bloodless field. For cementation, the knee irrigation removes lipids from the exposed bone along with meticulous cement technique. Tourniquetless TKA is able to be safely performed on a routine basis and brings potential benefits to the patient with no evident increased risk in comparison to tourniquet use.
Collapse
|
41
|
Rao SS, Chaudhry YP, Solano MA, Sterling RS, Oni JK, Khanuja HS. Routine Preoperative Nutritional Screening in All Primary Total Joint Arthroplasty Patients Has Little Utility. J Arthroplasty 2020; 35:3505-3511. [PMID: 32723504 DOI: 10.1016/j.arth.2020.06.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/15/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Nutritional optimization before total joint arthroplasty (TJA) may improve patient outcomes and decrease costs. However, the utility of serologic laboratory markers, including albumin, transferrin, and total lymphocyte count (TLC), as primary indicators of nutrition is unclear. We analyzed the prevalence of abnormal nutritional values before TJA and identified factors associated with them. METHODS We retrospectively reviewed 819 primary cases of TJA performed at 1 institution from January to December 2018. Patient demographic characteristics were assessed for associations with abnormal preoperative nutritional values (albumin <3.5 g/dL, transferrin <200 mg/dL, and TLC <1.5 cells/μL3). Associations of comorbidities, American Society of Anesthesiologists Physical Status classification, and age-adjusted Charlson Comorbidity Index (CCI) with abnormal values were assessed with logistic regression. RESULTS Values were abnormal for albumin in 21 cases (2.6%), transferrin in 26 cases (5.6%), and TLC in 185 cases (25%). Thirteen cases (1.7%) had abnormal values for 2 markers. Age was associated with abnormal albumin and TLC, and race with abnormal transferrin. Congestive heart failure, chronic kidney disease, pancreatic insufficiency, gastroesophageal reflux disease, osteoporosis, dementia, and CCI were associated with abnormal albumin; Parkinson disease and American Society of Anesthesiologists Physical Status with abnormal transferrin; and dementia, body mass index, cancer history, and CCI with abnormal TLC. CONCLUSION We report low prevalence of and a low concordance rate among abnormal nutritional values before primary TJA. Our results suggest that routine testing of all healthy patients is not warranted before TJA.
Collapse
Affiliation(s)
- Sandesh S Rao
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Yash P Chaudhry
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Mitchell A Solano
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD; Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| |
Collapse
|
42
|
Identification of Risk Factors for Readmission in Patients Undergoing Anterior Cervical Discectomy Fusion: A Predictive Risk Scale. Clin Spine Surg 2020; 33:E426-E433. [PMID: 32205517 DOI: 10.1097/bsd.0000000000000962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to analyze readmission rates among patients undergoing anterior cervical discectomy and fusion (ACDF), determine which factors were associated with higher readmission rates, and develop a scale for utilization during surgical planning. SUMMARY OF BACKGROUND DATA ACDF is the most common surgical treatment for many cervical disk pathologies. With the Centers for Medicare and Medicaid Services selecting readmissions as a measure of health care quality, there has been an increased focus on reducing readmissions. MATERIALS AND METHODS There were 114,174 recorded ACDF surgeries in the derivation cohort, the State Inpatient Database (SID) of New York and California between 2006 and 2014. There were 115,829 ACDF surgeries recorded in the validation cohort, the SID from Florida and Washington over the same time period. After identification of risk factors using univariate and multivariate analysis of the derivation cohort, a predictive scale was generated and tested utilizing the validation cohort. RESULTS Overall, readmission rates within 30 days of discharge were 5.87% and 5.52% in the derivation and validation cohorts, respectively. On multivariate analysis of the derivation cohort, age older than 80 years [odds ratio (OR), 1.67] male sex (OR, 1.16), Medicaid insurance (OR, 1.90), Medicare insurance (OR, 1.64), revision ACDF (OR, 1.43), anemia (OR, 1.45), chronic lung disease (OR, 1.23), coagulopathy (OR, 1.42), congestive heart failure (OR, 1.31), diabetes (OR, 1.23), fluid and electrolyte disorder (OR, 1.56), liver disease (OR, 1.37), renal failure (OR, 1.59), and myelopathy (OR, 1.19) were found to be statistically significant predictors for readmission. These factors were incorporated into a numeric scale that, that when tested on the validation cohort, could explain 97.1% of the variability in readmission rate. CONCLUSIONS Overall, 30-day readmission following ACDF surgery was 5%-6%. A novel risk scale based on factors associated with increased readmission rates may be helpful in identifying patients who require additional optimization to reduce perioperative morbidity. LEVEL OF EVIDENCE Level III-prognostic.
Collapse
|
43
|
Johns WL, Layon D, Golladay GJ, Kates SL, Scott M, Patel NK. Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:3353-3363. [PMID: 32600816 DOI: 10.1016/j.arth.2020.05.074] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/13/2020] [Accepted: 05/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA. METHODS A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria. RESULTS A total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285. CONCLUSIONS Implementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients' access to surgery. LEVEL OF EVIDENCE III, Systematic Review.
Collapse
Affiliation(s)
- William L Johns
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Daniel Layon
- Department of Orthopaedics, VCU Health, Richmond, VA
| | | | | | - Michael Scott
- Department of Anesthesiology, VCU Health, Richmond, VA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nirav K Patel
- Department of Orthopaedics, VCU Health, Richmond, VA
| |
Collapse
|
44
|
Tang H, Li H, Zhang S, Wang Y, Qu X, Yue B. Postoperative Complications Causing Readmission in 30 Days after Total Knee Arthroplasty: A Retrospective Nested Case-Control Study of Risk Factors Based on Propensity Score Matching. J Knee Surg 2020; 33:1100-1108. [PMID: 31357222 DOI: 10.1055/s-0039-1692630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We performed this study to identify independent risk factors for life-threatening postoperative complications causing 30-day readmissions after total knee arthroplasty (TKA). Improved understanding of these risks may improve efficiency and safety of treatment. We performed a retrospective, nested case-control study using an open-access database of 2,622 patients who underwent primary TKA at a tertiary academic medical center in Singapore between January 2013 and June 2014. Patients were grouped according to the incidence of complications. Multivariate logistic analysis was performed to identify predictive factors for TKA complications. The incidence of postoperative complications was 1.72%. Compared with cases performed with an operative time < 70 minutes, increased operative time was associated with a higher risk of complications. Case duration > 90 minutes was associated with an increased risk (adjusted odds ratio [aOR] = 4.57, p = 0.001; case duration ≥ 111 minutes, aOR = 4.64, p = 0.04; and case duration between 91 and 110 minutes, aOR = 3.20, p = 0.03). The correlation between operative time and complications was nonlinear. Cerebrovascular accident (CVA) or transient ischemic attack (TIA) was an independent risk factor for increased complication rate (aOR = 11.59, p = 0.02). Operative duration has been identified as an independent risk factor for complications after TKA. As it remains a modifiable factor to which doctors are interested in bringing quality improvement, the risk of postoperative complications will be reduced by minimizing the operative duration.
Collapse
Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| | - Hui Li
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| | - Shutao Zhang
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| | - You Wang
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| | - Bing Yue
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, People's Republic of China
| |
Collapse
|
45
|
Wasfie TJ, Groton J, Cwalina N, Hella JR, Barber K. Efficacy of Preoperative Usage of Dexamethasone in Diabetic Patients Undergoing Total Hip or Knee Arthroplasty for Control of Nausea and Vomiting. Am Surg 2020; 87:336-340. [PMID: 32967432 DOI: 10.1177/0003134820947391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dexamethasone has been used in surgical patients to decrease nausea, vomiting, and postoperative pain. However, it is not well studied how much dexamethasone complicates glucose control in diabetic patients and whether this leads to poor surgical outcomes. METHODS We analyzed 256 diabetic patients who underwent elective hip and knee arthroplasty and evaluated the groups that received dexamethasone intraoperatively (201 patients), those who received dexamethasone postoperatively (237 patients), and those who did not receive the steroid intraoperatively (55 patients) and postoperatively (19 patients). RESULTS 256 diabetic patients were included in the study. The mean age of the group was 68.7 (SD ± 9-10) years. Patients were divided into 123 males (48%) and 133 females (52%). 174 (78%) patients had a total knee replacement operation, and 82 (32%) patients had total hip replacement operation. The mean hemoglobin A1c was 6.728 (SD ± 0.99). The mean ASA score was 2.86 (SD ± 0.38). 201 (78.5%) patients received preoperative or intraoperative dexamethasone, and 237 (92.6%) patients received it postoperatively. The mean blood glucose for all patients raised from 131.9 to 172.2 mg/dL (P = .012) postoperatively, 206.1 mg/dL in the first 24 hours, and 146.2 mg/dL (P = .39) in the second postoperative day. The change was significant in patients who had poorly controlled diabetes (P < .01) preoperatively. There was no significant difference in our study regarding dexamethasone use and effect on postoperative nausea (P = 1.0) and vomiting (P = .52). There was an improvement in pain scores in the patients who received dexamethasone postoperatively which was statistically significant (P = .054). CONCLUSION Dexamethasone use in diabetic patients for control of postoperative nausea and vomiting in those undergoing elective total knee and hip arthroplasty had a negative impact on glycemic control specifically in those with poorly controlled diabetes and should be avoided.
Collapse
Affiliation(s)
- Tarik J Wasfie
- Department of Surgery and Orthopedic, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Jessica Groton
- Department of Surgery and Orthopedic, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Natalia Cwalina
- Department of Surgery and Orthopedic, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Jennifer R Hella
- Department of Academic Research, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Kimberly Barber
- Department of Academic Research, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| |
Collapse
|
46
|
Layon DR, Johns WL, Morrell AT, Perera R, Patel NK, Golladay GJ, Kates SL. Does Adherence to Preoperative Surgical Selection Criteria Reduce the Rate of Prosthetic Joint Infection in Primary and Revision Total Knee Arthroplasties? Arthroplast Today 2020; 6:410-413. [PMID: 32577486 PMCID: PMC7305334 DOI: 10.1016/j.artd.2020.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND There has been recent increased focus on the importance of modifiable risk factors that can affect the risk of potentially avoidable complications such as prosthetic joint infection (PJI). We aimed to assess the relationship between adherence to a preoperative optimization protocol at our institution and its influence on the rate of PJI after primary and revision total knee arthroplasty (TKA). METHODS A single-institution, retrospective study was conducted on all elective primary and revision TKAs performed over a 2-year period. PJI was diagnosed using the 2011 Musculoskeletal Infection Society criteria. Surgical outcomes and PJI were assessed relative to adherence to preoperative optimization criteria. Compliance was set as a binary variable with any case that did not meet all criteria deemed noncompliant. RESULTS A total of 669 TKAs met inclusion criteria, including 510 primary and 159 revision TKAs. Overall compliance was 61.3%. There were 26 PJIs (3.9%) in total. The PJI rate was 1.2% (6) among primary and 14.4% (20) among revision TKAs. The rate of PJI among cases that met the preoperative optimization criteria was 2.4% (5), and the rate among cases that did not was 6.2% (21) (P < .05). CONCLUSIONS Adherence to preoperative optimization criteria may decrease the incidence of PJI after primary and revision TKA, but further study is needed to confirm the findings of this study.
Collapse
Affiliation(s)
- Daniel R. Layon
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - William L. Johns
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Aidan T. Morrell
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Robert Perera
- Department of Biostatistics, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Nirav K. Patel
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Gregory J. Golladay
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
47
|
Ricciardi BF, Muthukrishnan G, Masters EA, Kaplan N, Daiss JL, Schwarz EM. New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection. J Orthop Res 2020; 38:1423-1435. [PMID: 31965585 PMCID: PMC7304545 DOI: 10.1002/jor.24595] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/03/2020] [Indexed: 02/04/2023]
Abstract
Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.
Collapse
Affiliation(s)
- Benjamin F Ricciardi
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Elysia A Masters
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Nathan Kaplan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - John L Daiss
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Edward M Schwarz
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| |
Collapse
|
48
|
Dlott CC, Moore A, Nelson C, Stone D, Xu Y, Morris JC, Gibson DH, Rubin LE, O'Connor MI. Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients. J Arthroplasty 2020; 35:1508-1515.e2. [PMID: 32113812 DOI: 10.1016/j.arth.2020.01.083] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The evaluation and management of outcomes risk has become an essential element of a modern total joint replacement program. Our multidisciplinary team designed an evidence-based tool to address modifiable risk factors for adverse outcomes after primary hip and knee arthroplasty surgery. METHODS Our protocols were designed to identify, intervene, and mitigate risk through evidence-based patient optimization. Nurse navigators screened patients preoperatively, identified and treated risk factors, and followed patients for 90 days postoperatively. We compared patients participating in our optimization program (N = 104) to both a historical cohort (N = 193) and a contemporary cohort (N = 166). RESULTS Risk factor identification and optimization resulted in lower hospital length of stay (LOS) and postoperative emergency department (ED) visits. Patients in the optimization cohort had a statistically significant decrease in mean LOS as compared to both the historical cohort (2.55 vs 1.81 days, P < .001) and contemporary cohort (2.56 vs 1.81 days, P < .001). Patients in the optimization cohort had a statistically significant decrease in 30- and 90-day ED visits compared to the historical cohort (P30-day = .042, P90-day = .003). When compared with the contemporary cohort, the optimization cohort had a statistically significant decrease in 90-day ED visits (21.08% vs 10.58%, P = .025). The optimization cohort had a statistically significant increase in the percentage of patients discharged home. We noted nonsignificant reductions in readmission rate, transfusion rate, and surgical site infections. CONCLUSION Optimization of patients before elective primary total hip arthroplasty and total knee arthroplasty reduced average LOS, ED visits, and drove telerehabilitation use. Our results add to the limited body of literature supporting this patient-centered approach.
Collapse
Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Anne Moore
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Christen Nelson
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Dannielle Stone
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Yunshan Xu
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Jensa C Morris
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - David H Gibson
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Lee E Rubin
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| | - Mary I O'Connor
- Department of Orthopaedics & Rehabilitation, Center for Musculoskeletal Care, Yale University School of Medicine, Yale New Haven Health, New Haven, CT
| |
Collapse
|
49
|
Halawi MJ, Mirza M, Osman N, Cote MP, Kerr JM, Huddleston JI. Quantifying Surgeon Work in Total Hip and Knee Arthroplasty: Where Do We Stand Today? J Arthroplasty 2020; 35:1170-1173. [PMID: 31883825 DOI: 10.1016/j.arth.2019.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Physician work is a critical component in determining reimbursement for total joint arthroplasty (TJA). The purpose of this study is to quantify the time spent during the different phases of TJA care relative to the benchmarks used by the Centers for Medicare and Medicaid Services. METHODS We retrospectively reviewed all patients captured in our institutional joint database between January 1, 2014, and December 31, 2018. Four phases of care were assessed: (1) preoperative period following the decision to proceed with TJA and leading to the day before surgery, (2) immediate 24 hours preceding surgery (preservice time), (3) operative time from skin incision to dressing application (intraservice time), and (4) postoperative work including day of surgery and the following 90 days. RESULTS A total of 666 procedures were analyzed (379 total hip arthroplasties and 287 total knee arthroplasties). The mean preoperative care coordination, preservice, intraservice, immediate postservice, and 91-day global period times were 21.9 ± 10, 84.1, 114 ± 24, 35, and 150 ± 37 minutes, respectively. Except for a slightly higher preoperative time associated with Medicare coverage (P = .031), there were no differences in the other phases of care by payer type. There were no temporal differences between 2014 and 2017. However, in 2018, there were significant increases in preoperative and intraservice times (6 and 20 minutes, respectively, P < .001) which were accompanied with a significant decrease in postoperative service time (34 minutes, P < .001). CONCLUSION Even when performing TJA under the most optimal conditions, the overall time has remained stable over the past 5 years and consistent with current benchmarks.
Collapse
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX
| | - Mohsin Mirza
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Nebiyu Osman
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
| | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Rosemont, IL
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA
| |
Collapse
|
50
|
Chen SA, White RS, Tangel V, Gupta S, Stambough JB, Gaber-Baylis LK, Weinberg R. Preexisting Opioid Use Disorder and Outcomes After Lower Extremity Arthroplasty: A Multistate Analysis, 2007–2014. PAIN MEDICINE 2020; 21:3624-3634. [DOI: 10.1093/pm/pnaa059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Objective
The aim of this study was to examine the association of preexisting opioid use disorder and postoperative outcomes in patients undergoing total hip or knee arthroplasty (THA and TKA, respectively) in the overall population and in the Medicare-only population.
Methods
This retrospective cohort study examined data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007–2014 from California, Florida, New York, Maryland, and Kentucky. We compared patients with and without opioid use disorders on unadjusted rates and calculated adjusted odds ratios (aORs) of in-hospital mortality, postoperative complications, length of stay, and 30-day and 90-day readmission status; analyses were repeated in a subgroup of Medicare insurance patients only.
Subjects
After applying our exclusion criteria, our study included 1,422,210 adult patients undergoing lower extremity arthroplasties, including 818,931 Medicare insurance patients. In our study, 0.4% of THA patients and 0.3% of TKA patients had present-on-admission opioid use disorder.
Results
Opioid use disorder patients were at higher risk for in-hospital mortality (aOR = 3.10), 30- and 90-day readmissions (aORs = 1.81, 1.81), and pulmonary and infectious complications (aORs = 1.25, 1.96).
Conclusions
Present-on-admission opioid use disorder was a risk factor for worse postoperative outcomes and increased health care utilization in the lower extremity arthroplasty population. Opioid use disorder is a potentially modifiable risk factor for mortality, postoperative complications, and health care utilization, especially in the at-risk Medicare population.
Collapse
Affiliation(s)
- Stephanie A Chen
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Virginia Tangel
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Soham Gupta
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Licia K Gaber-Baylis
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| |
Collapse
|