Sleep Apnea Increases Ninety-Day Complications and Cost Following Primary Total Joint Arthroplasty

Risk of Adverse Events Following Total Knee Arthroplasty in Asthma Patients

INTRODUCTION

Total knee arthroplasty (TKA) is a common procedure for which patient factors are known to affect perioperative outcomes. Asthma has not been specifically considered in this regard, although it is the most common inflammatory airway disease and predisposes to osteoarthritis.

METHODS

Adult patients undergoing TKA were identified from 2015 to 2021-Q3 M157 PearlDiver data sets. Asthma patients were matched to those without 1:1 based on age, sex, and Elixhauser Comorbidity Index (ECI). The incidence of 90-day adverse events and 5-year revisions were compared using multivariable logistic regression ( P < 0.0023). The matched asthma group was then stratified based on disease severity for analysis of 90-day aggregated (any, severe, and minor) adverse events.

RESULTS

Among 721,686 TKA patients, asthma was noted for 76,125 (10.5%). Multivariable analysis revealed that patients with asthma were at increased odds of multiple 90-day pulmonary, non-pulmonary, and aggregated adverse events, as well as emergency department visits. Furthermore, patients with asthma had 1.17 times greater odds of 5-year revisions ( P < 0.0001). Upon secondary analysis stratifying asthma by severity, patients with all severity levels of asthma showed elevated odds of adverse events after TKA. These associations increased in odds with increasing severity of asthma.

DISCUSSION

Over one-tenth of patients undergoing TKA were identified as having asthma, and these patients were at greater odds of numerous pulmonary and non-pulmonary adverse events (a trend that increased with asthma severity), as well as 5-year revisions. Clearly, patients with asthma need specific risk mitigation strategies when considering TKA.

LEVEL OF EVIDENCE

III.

Increased Risk of Postoperative Complications in Patients Who Have Obstructive Sleep Apnea Undergoing Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Obstructive sleep apnea (OSA) has been linked to multiple adverse health outcomes and postoperative complications. Despite the high prevalence of OSA in patients undergoing total joint arthroplasty (TJA), few studies have evaluated the postoperative course of OSA patients after joint arthroplasty surgery.

METHODS

PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) were used to conduct a systematic review of articles from inception to July 2023. Primary studies comparing postoperative outcomes following TJA between patients who had and did not have OSA were included. Postoperative medical complications, utilization of critical care, hospital stay, and mortality data were extracted. Descriptive statistics and random-effects meta-analysis models were used to analyze the available data. Included studies were evaluated for methodological risks of bias using the Risk of Bias in Nonrandomized Studies of Interventions. This review was registered on the International Prospective Register of Systematic Reviews (ID: CRD42023447610) RESULTS: There were seven studies with a total of 20,977 patients (9,425 Hip; 11,137 Knee; 415 Hip or Knee) that were included. Pulmonary complications were most frequently studied, followed by thromboembolic events. Cardiac, gastrointestinal, hematologic, genitourinary. and delirium events were also reported across studies. Meta-analysis revealed that OSA patients had 4-fold increased odds of overall medical complications (OR [odds ratio], 4.23; 95% CI [confidence interval], 2.97 to 6.04; P < 0.001; I2 = 0%), 4-fold increased odds of pulmonary complications (OR, 4.31; 95% CI, 2.82 to 6.60; P < 0.001; I2 = 0%), 2-fold increased odds of thromboembolic complications (OR, 1.92; 95% CI, 1.22 to 3.03; P = 0.005; I2 = 9%), and 4-fold increased odds of delirium (OR, 3.94; 95% CI, 1.72 to 9.04; P = 0.001; I2 = 0%).

CONCLUSION

A significant association was found between OSA and overall medical, pulmonary, and thromboembolic complications. These patients also had a higher incidence of postoperative delirium. The present findings underscore the need for comprehensive perioperative strategies to mitigate these risks in OSA patients who elect to undergo TJA.

The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total knee arthroplasty: a propensity score matched analysis

INTRODUCTION

Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited.

METHODS

A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years.

RESULTS

The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years.

CONCLUSION

Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group.

The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total hip arthroplasty: A propensity score matched analysis

Introduction

Obstructive sleep apnea (OSA) impacts approximately 936 million individuals globally and is known to complicate post-surgical recovery, particularly after total hip arthroplasty (THA). While continuous positive airway pressure (CPAP) is commonly recommended for managing OSA, its effect on THA recovery remains uncertain. The study aimed to assess the impact of CPAP use on post-THA outcomes in patients with OSA, focusing on medical complications and periprosthetic joint infection (PJI) at 90 days and 1 year.

Methods

A national, all-payer database was utilized to identify patients undergoing primary THA between 2010 and 2021. Patients with OSA were stratified based on CPAP use through propensity score matching. Three matched groups were formed: OSA without CPAP, OSA with CPAP, and no OSA. Medical and surgical complications were assessed at 90 days and 1 year post-THA.

Results

Patients with OSA using CPAP exhibited more baseline comorbidities than those without CPAP. CPAP use was associated with inferior outcomes, including higher odds of PJI, wound complications, and venous thromboembolism at 90 days and 1 year post-THA. These trends were consistent even after adjusting for confounders.

Conclusion

CPAP use, indicative of severe OSA, was linked to worse post-THA outcomes, emphasizing the importance of recognizing OSA severity preoperatively. The study does not advocate for or against CPAP use but underscores the heightened risk in this patient population, guiding clinicians in tailoring perioperative strategies and counseling patients about potential risks.

Sleep Apnea is Not an Obstacle for Outpatient Hip and Knee Arthroplasty

BACKGROUND

Up to 25% of patients requiring hip or knee arthroplasty have sleep apnea (SA), and these patients have historically been excluded from outpatient programs. The objectives of this study were to evaluate same-day discharge failure as well as 30-day complications, readmissions, and unexpected visits.

METHODS

A retrospective case-control study comparing patients who have and do not have SA matched for age, sex and arthroplasty type (total hip arthroplasty, total knee arthroplasty, unicompartimental knee arthroplasty) who underwent primary outpatient surgery between February 2019 and December 2022 in 2 academic hospitals was conducted. Cases with mild SA, moderate SA with a body mass index (BMI) <35, and SA of all severity treated by continuous positive airway pressure machines were eligible. There were 156 patients included (78 cases). Complications were assessed according to the Clavien-Dindo Classification and the Comprehensive Complication Index. Continuous variables were evaluated by Student's T or Mann-Whitney tests, while categorical data were analyzed by Chi-square or Fisher tests. Univariate analyses were performed to determine discharge failure risk factors.

RESULTS

There were 6 cases (7.7%) and 5 controls (6.4%) who failed to be discharged on surgery day (P = .754), with postoperative hypoxemia (6, [3.8%]) and apnea periods (3, [1.9%]) being the most common causes. Higher BMI (odds ratio = 1.19, P = .013) and general anesthesia (odds ratio = 11.97, P = .004) were found to be risk factors for discharge failure. No difference was observed on 30-day readmissions (P = .497), unexpected visits (P = 1.000), and complications on the Clavien-Dindo Classification (P > .269) and Comprehensive Complication Index (P > .334) scales.

CONCLUSIONS

Selected patients who have SA can safely undergo outpatient hip or knee arthroplasty. Higher BMI and general anesthesia increased the odds of same-day discharge failure.

LEVEL OF EVIDENCE

Level III, Case-control Study.

The impact of sleep apnea on primary reverse shoulder arthroplasty for the treatment of glenohumeral osteoarthritis

Introduction

As the prevalence of sleep apnea (SA) increases nationwide, large sample sized studies following primary reverse shoulder arthroplasty (RSA) in SA patients are scarce. Therefore, this study evaluated whether SA is associated with 1) longer in-hospital lengths of stay (LOS) 2) readmissions 3) medical complications and 4) costs.

Methods

A retrospective nationwide Medicare analysis from 2005 to 2014 was performed. Inclusion criteria were patients with SA undergoing RSA for the treatment of glenohumeral osteoarthritis. Study group patients were 1:5 ratio matched to controls yielding 6241 patients in the study and 31,179 in the comparison cohort. Logistic regression was used to calculate odds-ratios (OR) for readmissions and complications. A p-value less than 0.004 was significant.

Results

SA patients had significantly longer in-hospital LOS compared to their counterparts (3-days versus 2-days, p < 0.0001), but similar rates of 90-day readmissions (7.98% vs. 6.54%; OR: 1.00, p = 0.907). Patients with SA had significantly greater incidence and odds of 90-day medical complications (13.36% vs. 7.29%; OR: 1.42, p < 0.0001) and significantly higher 90-day costs ($16,529.16 vs. $14,789.15, p < 0.0001).

Conclusion

Patients with SA undergoing primary RSA for the treatment of glenohumeral OA have longer in-hospital LOS, increased medical complications, and costs of care. Readmissions were not more common.

Level of Evidence

III.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Regional Anesthesia Techniques for Shoulder Surgery in High-Risk Pulmonary Patients

Patients with pre-existing pulmonary conditions are at risk for experiencing perioperative complications and increased morbidity. General anesthesia has historically been used for shoulder surgery, though regional anesthesia techniques are increasingly used to provide anesthesia and improved pain control after surgery. Relative to regional anesthesia, patients who undergo general anesthesia may be more prone to risks of barotrauma, postoperative hypoxemia, and pneumonia. High-risk pulmonary patients, in particular, may be exposed to these risks of general anesthesia. Traditional regional anesthesia techniques for shoulder surgery are associated with high rates of phrenic nerve paralysis which significantly impairs pulmonary function. Newer regional anesthesia techniques have been developed, however, that provide effective analgesia and surgical anesthesia while having much lower rates of phrenic nerve paralysis, thereby preserving pulmonary function.

The Use of Continuous Positive Airway Pressure for Patients With Obstructive Sleep Apnea is Associated With Early Medical and Surgery-Related Complications Following Total Knee Arthroplasty: A National Database Study

Background

Obstructive sleep apnea (OSA) has been shown to increase the risk of complications following total knee arthroplasty (TKA) although prior studies were limited by their ability to stratify OSA patients by disease severity. The objective of this study was to determine the effect size of the use of continuous positive airway pressure (CPAP) on early medical and surgery-related complications following TKA among patients with OSA.

Methods

Patients with OSA who underwent primary TKA were identified using the PearlDiver Mariner database. Ninety-day incidences of medical complications and 1-year incidences of surgery-related complications as well as hospital utilization were evaluated for OSA patients who had used CPAP prior to TKA compared to those who did not.

Results

CPAP patients were at increased 90-day risk of emergency department presentation (odds ratio [OR] 1.61; P < .0001), hospital admission (OR 1.33; P < .001), ICU admission (OR 1.45, P < .0001), pulmonary embolism (OR 1.68, P < .0001), deep vein thrombosis (OR 1.31, P < .0001), transfusion (OR 1.89, P < .0001), pneumonia (OR 1.63, P < .0001), cerebrovascular accident (OR 1.92, P < .0001), myocardial infarction (OR 1.57, P = .0015), sepsis (OR 1.35, P = .0025), blood loss anemia (OR 1.67, P < .0001), acute kidney injury (OR 1.65, P < .0001), and urinary tract infection (OR 1.99, P < .0001), as well as increased 1-year risk of undergoing revision surgery (OR 1.14, P = .0028), compared to OSA patients not using CPAP.

Conclusions

OSA patients on CPAP undergoing TKA have significantly increased complication rates compared to OSA patients not using CPAP.

Level of Evidence

III, Retrospective review.

Assessing Appropriateness for Shoulder Arthroplasty Using a Shared Decision-Making Process

Purpose

The primary purpose of this study was to validate an appropriateness decision-aid tool as a part of engaging patients with glenohumeral arthritis in their surgical management. The associations between the final decision to have surgery and patient characteristics were examined.

Materials and Methods

This was an observational study. The demographics, overall health, patient-specific risk profile, expectations, and health-related quality of life were documented. Visual analog scale and the American Shoulder & Elbow Surgeon (ASES) measured pain and functional disability, respectively. Clinical and imaging examination documented clinical findings and extent of degenerative arthritis and cuff tear arthropathy. Appropriateness for arthroplasty surgery was documented by a 5-item Likert response survey and the final decision was documented as ready, not-ready, and would like to further discuss.

Results

Eighty patients, 38 women (47.5%), mean age: 72(8) participated in the study. The appropriateness decision aid showed excellent discriminate validity (area under the receiver operating characteristic curve value of 0.93) in differentiating between patients who were “ready” and those who were “not-ready” to have surgery. Gender ( P  =  0.037), overall health ( P  =  .024), strength in external rotation ( P  =  .002), pain severity ( P  =  .001), ASES score ( P < .0001), and expectations ( P  =  .024) were contributing factors to the decision to have surgery. Imaging findings did not play a significant role in the final decision to have surgery.

Conclusions

A 5-item tool showed excellent validity in differentiating patients who were ready to have surgery versus those who were not. Patient's gender, expectations, strength, and self-reported outcomes were important factors in reaching the final decision.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis

BACKGROUND

Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures.

METHODS

The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant.

RESULTS

The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5 days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001).

CONCLUSION

SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure.

LEVEL OF EVIDENCE

III.

Heart Failure is Associated with Early Medical and Surgery-Related Complications Following Total Hip Arthroplasty: A Propensity-Scored Analysis

INTRODUCTION

There is a paucity of literature that examines how heart failure (HF) impacts surgery-related complications following total hip arthroplasty (THA). We hypothesized that patients who had HF will be at increased risk of early medical- and surgery-related complications following THA.

METHODS

Patients who had HF and underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical complications, surgery-related complications, and hospital utilizations were evaluated for patients who did and did not have HF, as well as subgroup analyses were performed on patients who were prescribed mortality-benefitting medications for HF 1 year prior to THA. Propensity score matching resulted in 34,000 HF patients who underwent primary THA and 340,000 matching patients.

RESULTS

The HF cohort was associated with a higher 90-day incidence of pulmonary embolism (PE), deep vein thrombosis (DVT), transfusion, pneumonia, cerebrovascular accident (CVA), myocardial infarction (MI), sepsis, acute post hemorrhagic anemia, acute renal failure (ARF), and urinary tract infection (UTI), as well as 1-year risk of revision THA, periprosthetic joint infection (PJI), aseptic loosening, and dislocation compared to controls. The HF cohort was associated with a higher 90-day incidence of emergency department visits, readmissions, lengths of stay (LOS), and 1-year costs of care. The medication cohort was at decreased risk of PE, DVT, CVA, return to ED, readmission and MI within 90 days of surgery, and 1-year risk of revision THA and aseptic loosening.

DISCUSSION

These findings may help to better risk-stratify patients who have HF and are scheduled to undergo THA, as well as call for additional surveillance of these patients in the immediate and early postoperative period. This study also helps surgeons and internists understand how chronic medications used to treat HF can impact medical- and surgery-related outcomes following THA.

The Use of Continuous Positive Airway Ventilation for Patients With Obstructive Sleep Apnea is Associated With Early Medical and Surgery-related Complications Following Total Hip Arthroplasty: A National Database Study

Background

The objective of this study was to determine the effect size of the use of continuous positive airway pressure (CPAP), as a surrogate in cases of active and more severe diseases, on early medical and surgery-related complications following total hip arthroplasty (THA) within an obstructive sleep apnea (OSA) patient population.

Methods

Patients with OSA who underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical and surgery-related complications and hospital utilization were evaluated for OSA patients who had used CPAP prior to THA and those who did not. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates.

Results

Propensity score matching resulted in 7351 OSA patients who had used CPAP within 6 months of primary THA and 7351 OSA patients who had not. Patients who had used CPAP were at increased 90-day risk of medical complications, as well as 1-year risk of periprosthetic fracture (OR 1.5429; P = .0356), osteolysis (OR 2.4488; P = .0237), aseptic loosening (OR 2.4057; P < .001), and dislocation (OR 1.283; P = .016).

Conclusions

Our findings suggest that OSA patients on CPAP are at increased risk of several 90-day medical complications, 1-year surgical complications, and health-care utilization compared to OSA patients not recently using CPAP.

Level of Evidence

III, Retrospective review.

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

➤

There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.

➤

The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.

➤

Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.

➤

Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.

➤

Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.

➤

Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids.

Impact of Biological Sex on Complications, Lengths of Stay, Readmission Rates, and Costs of Care Following Primary Total Knee Arthroplasty

The impact of gender on total knee arthroplasty (TKA) postoperative complications, readmission rates, and costs of care has not been often evaluated. Therefore, the purpose of this study was to investigate which sex had higher rates of: (1) medical complications; (2) implant complications; (3) lengths of stay (LOSs); (4) readmission rates; and (5) costs after TKA. A query was performed using an administrative claims database from January 1, 2005, to March 31, 2015. Patients who had TKAs were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Males and females were filtered separately and matched according to age and various medical comorbidities leading to 1,590,626 patients equally distributed. Primary outcomes analyzed included 90-day medical complications, LOSs, 90-day readmission rates, in addition to day of surgery and total global 90-day episode of care costs. Pearson's chi-square analyses were used to compare medical complications and readmission rates. Welch's t-tests were used to test for significance in matching outcomes and costs. A p-value of less than 0.01 was considered statistically significant. Males had a smaller risk of complications than women (1.35 vs. 1.40%, p < 0.006) and higher rates of implant-related complications (2.28 vs. 1.99%, p < 0.0001). Mean LOSs were lower for males: 3.16 versus 3.34 days (p < 0.0001). The 90-day readmission rates were higher in men (9.67 vs. 8.12%, p < 0.0001). This study demonstrated that males undergoing primary TKA have lower medical complications and shorter LOSs then their female counterparts. However, males have higher implant-related complications, readmission rates, and costs of care.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures

INTRODUCTION

Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures.

METHODS

A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant.

RESULTS

There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001).

CONCLUSION

This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Retrospective.

A nationwide analysis on the effects of chronic obstructive pulmonary disease following primary total shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND

Chronic obstructive pulmonary disease patients have been shown in orthopedic literature to have poorer outcomes and higher rates of complications from surgery. In this retrospective review, medical complications, length of stay, and costs were obtained to explore the effects of chronic obstructive pulmonary disease on patients undergoing primary total shoulder arthroplasty.

METHODS

Total shoulder arthroplasty cases from January 2005 to March 2014 were queried and analyzed from a nationwide database. Study patients were matched 1:5 to controls by age, sex, and medical comorbidities associated with chronic obstructive pulmonary disease. In-hospital length of stay, 90-day medical complications, day of surgery, and total global 90-day episode of care costs were obtained for comparison.

RESULTS

Chronic obstructive pulmonary disease patients were found to have higher incidence and odds (53.91 vs. 11.95%; OR: 3.58, 95%CI: 3.18-3.92, p < 0.0001) of 90-day medical complications, longer in-hospital length of stay (3 vs. 2 days, p < 0.0001), and significantly higher 90-day costs ($14,768.37 vs. $13,379.20, p < 0.0001) following primary total shoulder arthroplasty compared to matched controls.

DISCUSSION

Chronic obstructive pulmonary disease patients undergoing primary total shoulder arthroplasty have higher rates of medical complications, in-hospital length of stay, and costs of care. This represents an important factor that will allow orthopedic surgeons to adequately manage expectations and educate chronic obstructive pulmonary disease patients of the potential complications which may occur following total shoulder arthroplasty.

The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty

Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA.

Editorial Commentary: Sleep Disorders in Rotator Cuff Diseases

One of the most common complaints expressed by patients with rotator cuff disease is poor-quality sleep. Sleeping significantly affects daily life, influencing biological functions, learning, memory, and cognitive processes. The etiology of nocturnal shoulder pain is controversial, yet there is a consensus that high levels of proinflammatory factors and pain-related cytokines are involved in the pathogenesis of this disturbance in patients with shoulder rotator cuff pathology. Unfortunately, many variables, including body mass index, depression, sex, low back pain, cervical pain, diabetes, narcotics, pain, pain perception, and sleeping position (which may influence tendon perfusion), could influence sleep quality in both healthy patients and patients with rotator cuff pathology. For now, it is not possible to assess the real influence of rotator cuff repair surgery on sleep quality improvement.

Impact of Parkinson's Disease on Complications, Readmission Rates, and Costs of Care following Primary Total Knee Arthroplasty

Large-scale studies evaluating the effects of Parkinson's disease (PD) on primary total knee arthroplasty (TKA) are limited. The purpose of this study was to determine if PD patients undergoing primary TKA have increased: (1) medical complications; (2) implant-related complications; (3) readmission rates; and (4) costs. A query was performed using an administrative claims database. The study group consisted of all patients undergoing primary TKA who had a history of PD. Matched non-PD patients undergoing primary TKA served as a control group. The query yielded 72,326 patients (PD = 18,082; matching cohort = 54,244). Pearson's chi-square tests, logistic regression analyses, and Welch's t-tests were used to test for significance between the cohorts. Primary TKA patients who had PD were found to have greater incidences and odds of medical complications (4.21 vs. 1.24%; odds ratio [OR]: 3.50, 95% confidence interval [CI]: 3.15-3.89, p < 0.0001) and implant-related complications (5.09 vs. 3.15%; OR: 1.64, 95% CI: 1.51-1.79, p < 0.0001) compared with the matching cohort. Additionally, the rates and odds of 90-day readmission were higher (16.29 vs. 12.66%; OR:1.34, p < 0.0001) and episodes of care costs were significantly greater ($17,105.43 vs. $15,252.34, p < 0.0001) in patients who had PD. Results demonstrate that PD patients undergoing primary TKA had higher incidences of medical and implant-related complications. They also had increased 90-day readmission rates and costs compared with controls. The findings of this study should be used in risk stratification and should inform physician-patient discussion but should not be arbitrarily used to deny access to care.

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients

BACKGROUND

This study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs).

METHODS

Between July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index.

RESULTS

Before surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3).

CONCLUSION

Improvement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.

Pulmonary complications in trauma patients with obstructive sleep apnea undergoing pelvic or lower limb operation

Background

Obstructive sleep apnea (OSA) is increasingly prevalent in the range of 2% to 24% in the US population. OSA is a well-described predictor of pulmonary complications after elective operation. Yet, data are lacking on its effect after operations for trauma. We hypothesized that OSA is an independent predictor of pulmonary complications in patients undergoing operations for traumatic pelvic/lower limb injuries (PLLI).

Methods

Nationwide Inpatient Sample (2009–2013) was queried for International Classification of Diseases, Ninth Revision, Clinical Modification codes for PLLI requiring operation. Elective admissions and those with concurrent traumatic brain injury with moderate to prolonged loss of consciousness were excluded. Outcome measures were pulmonary complications including ventilatory support, ventilator-associated pneumonia, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), and respiratory failure. Multivariable logistic regression analysis was used, adjusting for OSA, age, sex, race/ethnicity, and specific comorbidities (obesity, chronic lung disease, and pulmonary circulatory disease). P<0.01 was considered statistically significant.

Results

Among the 337 333 patients undergoing PLLI operation 3.0% had diagnosed OSA. Patients with OSA had more comorbidities and were more frequently discharged to facilities. Median length of stay was longer in the OSA group (5 vs 4 days, p<0.001). Pulmonary complications were more frequent in those with OSA. Multivariable logistic regression showed that OSA was an independent predictor of ventilatory support (adjusted odds ratio (aOR), 1.37; 95% CI,1.24 to 1.51), PE (aOR 1.40; 95% CI, 1.15 to 1.70), ARDS (aOR 1.36; 95% CI,1.23 to 1.52), and respiratory failure (aOR 1.90; 95% CI, 1.74 to 2.06).

Conclusion

OSA is an independent and underappreciated predictor of pulmonary complications in those undergoing emergency surgery for PLLI. More aggressive screening and identification of OSA in trauma patients undergoing operation are necessary to provide closer perioperative monitoring and interventions to reduce pulmonary complications and improve outcomes.

Level of evidence

Prognostic Level IV.

The Effects of Opioid Use on Thromboembolic Complications, Readmission Rates, and 90-Day Episode of Care Costs After Total Hip Arthroplasty

BACKGROUND

The purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non-opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care.

METHODS

All patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs.

RESULTS

Patients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P < .0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P < .001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P < .0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P < .0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients.

CONCLUSION

These findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.

Patients Who Have Cannabis Use Disorder Have Higher Rates of Venous Thromboemboli, Readmission Rates, and Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Studies have shown that cannabis can interfere with hematological parameters and platelet morphology. The purpose of this study is to investigate whether patients with cannabis use disorder undergoing primary total knee arthroplasty (TKA) have higher rates of (1) venous thromboemboli (VTEs); (2) readmissions; and (3) costs.

METHODS

Study group patients undergoing primary TKA were identified from a large, nationwide database. Patients who had a history of VTEs, deep vein thromboses (DVTs), pulmonary emboli (PEs), and coagulopathies before their TKA were excluded. Study group patients were matched to controls in a 1:4 ratio by age, sex, a comorbidity index, and medical comorbidities. The query yielded 18,388 patients (cannabis = 3680; controls = 14,708). Outcomes analyzed included rates of 90-day VTEs, DVTs, and PEs, in addition to 90-day readmissions and costs. A P value less than .01 was considered statistically significant.

RESULTS

Patients who have cannabis use disorder were found to have significantly higher incidence and odds (2.79% vs 1.78%; odds ratio [OR], 1.58; P < .0001) of VTEs, DVTs (2.41% vs 1.44%; OR, 1.68; P < .0001), and PEs (0.97% vs 0.62%; P = .01). Readmissions were significantly higher (27.03% vs 23.18%; OR, 1.22; P < .0001) in patients who have cannabis use disorder. Patients with cannabis use disorder have significantly higher day of surgery ($14,024.88 vs $12,127.49; P < .0001) and 90-day costs ($19,155.45 vs $16,315.00; P < .0001).

CONCLUSION

This study found that patients who have a cannabis use disorder have higher rates of thromboembolic complications, readmission rates, and costs following primary TKA compared to a matched cohort.

A Nationwide Analysis on the Impact of Schizophrenia Following Primary Total Knee Arthroplasty: A Matched-Control Analysis of 49,176 Medicare Patients

BACKGROUND

The influence of schizophrenia on total knee arthroplasty (TKA) is limited in the literature. Therefore, the purpose of this study was to investigate whether patients with schizophrenia undergoing primary TKA have (1) longer in-hospital length of stay (LOS); (2) higher readmission rates; (3) higher medical complications; (4) higher implant-related complications; and (5) higher costs of care compared to controls.

METHODS

Patients with schizophrenia undergoing primary TKA were identified within the Medicare claims database. The study group was randomly matched in a 1:5 ratio to controls according to age, sex, and medical comorbidities. The query yielded 49,176 patients with (n = 8,196) and without (n = 40,980) schizophrenia undergoing primary TKA. Primary outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to day of surgery and 90-day costs of care. A P-value less than .01 was considered statistically significant.

RESULTS

Schizophrenia patients had longer in-hospital LOS (3.73 days vs 3.22 days, P < .0001) and had higher incidence and odds ratios (ORs) of readmission rates (18.26 vs 12.07%; OR: 1.58, P < .0001) compared to controls. Schizophrenia patients had higher incidence and odds of medical (3.23 vs 1.10%; OR: 2.99, P < .0001) and implant-related complications (5.92 vs 3.59%; OR: 1.68, P < .0001) and incurred significantly higher day of surgery ($13,300.58 vs $11,681.77, P < .0001) and 90-day costs of care ($18,222.18 vs $14,845.64, P < .0001).

CONCLUSION

This study demonstrates that patients with schizophrenia have longer in-hospital LOS, higher readmission rates, higher complications, and increased costs of care after primary TKA.