A Simple Protocol to Stratify Pulmonary Risk Reduces Complications After 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.

Chronic Obstructive Pulmonary Disease is Associated With Serious Infection and Venous Thromboembolism in Patients Undergoing Hip or Knee Arthroplasties: A Meta-Analysis of Observational Studies

BACKGROUND

Although previous studies evaluated postoperative outcomes of arthroplasty patients with chronic obstructive pulmonary disease (COPD), no meta-analysis has been conducted.

METHODS

An electronic search was conducted on PubMed, Embase, and Cochrane Library databases to identify relevant studies published from inception to May 1, 2022. To assess the impact of COPD on postoperative outcomes, the odds ratios and 95% confidence intervals were calculated; pooled results were calculated using a random effects model. Sensitivity and subgroup analyses were carried out according to surgical type and statistical method. A total of 11 retrospective cohort studies involving patients with COPD who underwent hip or knee arthroplasties were included in the meta-analysis. There were 195,444 patients with COPD and 1,592,908 patients without COPD.

RESULTS

A pooled analysis showed that the COPD group was at higher risk for mortality, readmission, pneumonia, sepsis, septic shock, and surgical site infection within 30 days following hip arthroplasties than the non-COPD group. Moreover, COPD patients were more likely to experience mortality, readmission, pneumonia, sepsis, septic shock, and surgical site infection 30 days after knee arthroplasties.

CONCLUSION

In this study, coexisting COPD was associated with worse outcomes in patients with lower extremity joint arthroplasties. The findings highlighted the importance of preoperative optimization and proactive interventions for COPD in the perioperative period.

Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty

Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

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

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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.

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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.

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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.

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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.

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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.

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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.