The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

The dynamics of perioperative serum albumin before and after total knee arthroplasty

Background

Previous studies have evaluated preoperative serum albumin (SA) for predicting postoperative complications of total knee arthroplasty (TKA). This study aimed to investigate the dynamics of perioperative SA and changes in SA (ΔSA) and identify any influential patient or surgical factors.

Methods

In total, 381 patients (483 knees) undergoing primary TKA were recruited. SA values preoperatively (SA0), 1 week postoperatively (SA1W), and 4 weeks postoperatively (SA4W) were investigated. SA values were converted to a percentage of SA0 and differences between timepoints were calculated and expressed as follows: ΔSA1W-0, ΔSA4W-1W, and ΔSA4W-0. Patient and surgical factors previously identified or with the potential to influence SA were evaluated.

Results

The median values of SA0, SA1W, and SA4W were 4.4, 3.8, and 4.2 g/dL, respectively; SA0 was significantly different between groups (p < 0.001). The incidence of low SA0 (<3.5 g/dL) was less than 1 %. Median ΔSA values were -13.7 %, 9.6 %, and -4.5 % for ΔSA1W-0, ΔSA4W-1W and ΔSA4W-0, respectively; ΔSA was significantly different between groups (p < 0.001). SA4W recovered to 95.5 % of SA0 with less than 2 % of patients having low SA4W (<3.5 g/dL). Multiple regression analyses showed SA concentration at each timepoint was significantly associated with the other SA timepoint values; age was significantly associated with SA4W and SA1W (all p < 0.001).

Conclusions

We identified SA0 and age as significant factors affecting SA dynamics in the perioperative period. Low SA (<3.5 g/dL) was uncommon both preoperatively and at 4 weeks postoperatively; therefore, conventional cutoff values and preventive measures for low SA may need reconsideration.

Total Hip Arthroplasty Patients Who Have Ostomies Have an Increased Risk of Revisions for Periprosthetic Joint Infection, but Total Knee Arthroplasty Patients Do Not

BACKGROUND

Patient comorbidities can lead to worse outcomes and increase the risk of revisions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Sparse research is available on the effects of ostomies on postoperative outcomes. Our study aimed to assess whether patients who have ostomies, who underwent TKA or THA, have worse outcomes and increased rates of all-cause and periprosthetic joint infection (PJI)-related revisions.

METHODS

We performed a retrospective cohort study comparing the outcomes of THA and TKA patients who have and do not have a history of ostomy using the Statewide Planning and Research Cooperative System. Patient demographics, ostomy diagnosis, 3-month emergency department visits and readmissions, and revisions were collected. A total of 126,414 THA and 216,037 TKA cases were included. Log-rank testing and a Cox proportional hazards model were used to account for covariates.

RESULTS

In total, 463 THA patients (0.4%) had ostomies. They had a longer length of stay (4.0 versus 3.1 days, P < 0.001) and were less likely to be discharged home (55.3 versus 62.2%, P = 0.01). They had higher rates of PJI-related revisions (1.9 versus 0.9%, P = 0.02) and had increased odds of PJI-related revision (OR [odds ratio] = 2.2, P = 0.02). Of TKA patients, 619 patients (0.3%) had an ostomy. They had a longer length of stay (3.6 versus 3.3 days, P = 0.02) and was less likely to be discharged home (49.4 versus 52.4%, P = 0.16). However, there was no difference in the rate (1.8 versus 1.4%, P = 0.49) or odds (OR = 1.2, P = 0.53) of PJI-related revision.

CONCLUSIONS

THA, but not TKA, patients who have ostomies have an increased risk of PJI-related revisions. The proximity of the surgical incision to the ostomy site may play a role in the risk of PJI in THA patients.

Preoperative low serum albumin increases the rate of perioperative blood transfusion in patients undergoing total joint arthroplasty: propensity score matching

BACKGROUND

To investigate the relationship between preoperative low serum albumin and perioperative blood transfusion in patients undergoing total joint arthroplasty (TJA).

METHODS

We enrolled 2,772 TJA patients from our hospital between January 1, 2017, and January 1, 2022. Clinical data were extracted from electronic medical records, including patient ID, sex, BMI (Body Mass Index), age, and diagnoses. Receiver operating characteristic curves were constructed to establish thresholds for serum albumin levels categorization. Propensity score matching (PSM) was developed with preoperative serum albumin as the dependent variable and perioperative blood transfusion-related factors as covariates, including BMI grade, age grade, sex, diagnosis, hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease, chronic bronchitis, cerebral infarction, major surgeries within the last 12 months, renal failure, cancer, depression, corticosteroid use, smoking, drinking, and blood type. The low serum albumin group was matched with the normal albumin group at a 1:2 ratio, employing a caliper value of 0.2. Binary logistic regression was employed to analyze the outcomes.

RESULTS

An under the curve of 0.601 was discovered, indicating a cutoff value of 37.3 g/L. Following PSM, 892 cases were successfully paired in the low serum (< 37.3 g/L) albumin group, and 1,401 cases were matched in the normal serum albumin (≥ 37.3 g/L) group. Binary logistic regression in TJA patients showed that the albumin OR was 0.911 with 95%CI 0.888-0.935, P < 0.001. Relative to the preoperative normal serum albumin group, TJA patients in the low serum albumin group experienced a 1.83-fold increase in perioperative blood transfusion rates (95% CI 1.50-2.23, P < 0.001). Compared to the normal serum albumin group, perioperative blood transfusion rates for TJA patients with serum albumin levels of 30-37.3 g/L, 25-30 g/L, and ≤ 25 g/L increased by 1.63 (95% CI 1.37-1.99, P < 0.001), 5.4 (95% CI 3.08-9.50, P < 0.001), and 6.43 times (95% CI 1.80-22.96, P = 0.004), respectively.

CONCLUSION

In TJA patients, preoperative low serum albumin levels have been found to be associated with an increased risk of perioperative blood transfusion. Furthermore, it has been observed that the lower the preoperative serum albumin level is, the higher the risk of perioperative blood transfusion.

TRIAL REGISTRATION

28/12/2021, Chinese Clinical Trial Registry, ChiCRT2100054844.

The Effect of Nutritional Status in the Treatment of Periprosthetic Joint Infections in Total Hip Arthroplasty

BACKGROUND

Periprosthetic joint infections (PJIs) continue to be a complication that plagues arthroplasty. Albumin is a surrogate marker for nutrition as well as chronic inflammation, and hypoalbuminemia increases the risk of complications in arthroplasty. Patients with PJI are at increased risk for malnutrition and complications. This study's objective was to analyze patients who underwent treatment of PJI following total hip arthroplasty and investigate the outcome with regards to albumin levels.

METHODS

Overall, 48 patients who underwent surgery for a total hip PJI at 1 institution were reviewed. Albumin and C-reactive protein were recorded preoperatively and 2 to 3 weeks postoperatively. Treatment failure was determined by further surgical treatment for PJI or repeat infection, as determined by Musculoskeletal Infection Society guidelines.

RESULTS

A debridement, antibiotics, and implant retention procedure was performed in 39 patients, and explant with the placement of an antibiotic spacer was performed in 9. Preoperative mean albumin levels were significantly decreased in patients who failed to clear their infection compared to patients who remained infection-free (2.5 versus 3.3, P < .001). Postoperative albumin levels decreased in this same population (2.6 versus 3.8, P < .001). C-reactive protein was elevated in patients who failed to clear their infection preoperatively (19.9 versus 7.5, P < .001) and postoperatively (7.0 versus 1.7, P < .001). The average time to repeat surgical treatment for their PJI was 9 months CONCLUSIONS: Lower albumin levels are observed in patients with PJI who failed to remain infection-free after surgery. Albumin is a surrogate marker for nutrition, and low albumin is associated with poor immune function. Hypoalbuminemia is found with chronic inflammation as well as malnutrition. Nutritional reserves are diverted to the acute inflammatory response during an infection, which can lead to a deficient state. Further research may develop treatments to alter this modifiable risk factor.

LEVEL OF EVIDENCE

Level 4.

The Investigation of Preoperative Factors Associated With Postoperative Outcomes Following Total Knee Arthroplasty for Osteoarthritis: A Scoping Review

This study aimed to investigate preoperative factors associated with non-home discharges from acute care hospitals in patients undergoing total knee arthroplasty (TKA) due to osteoarthritis. It was a scoping review focused on patients who received their first unilateral TKA for osteoarthritis. The research targeted observational studies that examined the destinations of patients post-surgery based on preoperative factors, with a literature search conducted in April 2023. Out of 3,255 identified papers, 28 met the eligibility criteria. A total of 26 preoperative factors were identified as potentially related to discharge destinations, including age, gender, comorbidities, and obesity. By selecting an appropriate discharge destination based on preoperative factors, there may be potential for more efficient use of medical resources. Future studies should consider preoperative factors in the context of national healthcare systems and lengths of hospital stay.

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes

» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series

Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

The geriatric nutritional risk index as a strong predictor of adverse outcomes following total shoulder arthroplasty

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple readily available measure of malnutrition risk, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 3 groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Compared to normal nutrition, moderate malnutrition was independently significantly associated with a greater likelihood of any complications (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.54-1.96; P < .001), blood transfusions (OR: 1.52, 95% CI: 1.09-2.11; P = .013), failure to wean off a ventilator within 48 hours (OR: 3.84, 95% CI: 1.26-11.72; P = .018), wound dehiscence (OR: 15.80, 95% CI: 1.61-155.28; P = .018), nonhome discharge (OR: 1.90, 95% CI: 1.63-2.22; P < .001), readmission (OR: 1.54, 95% CI: 1.19-1.99; P = .001), unplanned reoperation (OR: 1.87, 95% CI: 1.27-2.74; P = .001), length of stay > 2 days (OR: 1.85, 95% CI: 1.63-2.12; P < .001), and mortality (OR: 3.38, 95% CI: 1.32-8.71; P = .011). Severe malnutrition was independently significantly associated with a greater likelihood of any complication (OR: 3.33, 95% CI: 2.80-3.97; P < .001), sepsis (OR: 9.83, 95% CI: 2.94-32.85; P < .001), pneumonia (OR: 3.30, 95% CI: 1.71-6.38; P < .001), unplanned reintubation (OR: 5.77, 95% CI: 2.47-13.51; P < .001), urinary tract infection (OR: 2.15, 95% CI: 1.19-3.87; P = .011), stroke (OR: 3.57, 95% CI: 1.18-10.84; P = .024), blood transfusions (OR: 5.27, 95% CI: 3.86-7.20; P < .001), failure to wean off a ventilator within 48 hours (OR: 7.64, 95% CI: 2.29-25.55; P < .001), Clostridioides difficile infection (OR: 4.17, 95% CI: 1.21-14.32; P = .023), nonhome discharge (OR: 3.56, 95% CI: 2.92-4.34; P < .001), readmission (OR: 2.05, 95% CI: 1.46-2.89; P < .001), length of stay > 2 days (OR: 3.27, 95% CI: 2.73-3.92; P < .001), and mortality (OR: 4.61, 95% CI: 1.51-14.04; P = .007).

Conclusion

Malnutrition based on GNRI is a strong predictor of complications following TSA, with increasing severity related to an increased rate of complications.

Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication

BACKGROUND

Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database.

METHODS

With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing.

RESULTS

Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims.

CONCLUSIONS

Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Does the geriatric nutritional risk index predict complication rates and implant survivorship in revision total joint arthroplasty?

INTRODUCTION

Malnutrition is associated with poorer outcomes after revision total joint arthroplasty (rTJA), though no universal metric for assessing malnutrition in rTJA patients has been reported. This study sought to determine if malnutrition as defined by the Geriatric Nutritional Risk Index (GNRI) can independently predict short-term complication rates and re-revision risk in patients undergoing rTJA.

METHODS

All patients ≥ 65 years old undergoing rTJA from 2011 to 2021 at a single orthopaedic specialty hospital were identified. Preoperative albumin, height, and weight were used to calculate GNRI. Based on the calculated GNRI value, patients were stratified into three groups: normal nutrition (GNRI > 98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI < 92). Chi-squared and independent samples t-tests were used to compare groups.

RESULTS

A total of 531 rTJA patients were included. Patients with normal nutrition were younger (p < 0.001), had higher BMI (p < 0.001). After adjusting for baseline characteristics, patients with severe and moderate malnutrition had longer length of stay (p < 0.001), were less likely to be discharged home (p = 0.049), and had higher 90-day major complication (p = 0.02) and readmission (p = 0.005) rates than those with normal nutrition. 90-day revision rates were similar. In Kaplan-Meier analyses, patients with severe and moderate malnutrition had worse survivorship free of all-cause re-revision at 1-year (p = 0.001) and 2-year (p = 0.002) follow-up compared to those with normal nutrition.

CONCLUSION

Moderate and severe malnutrition, as defined by GNRI, independently predicted higher complication and revision rates in rTJA patients. This suggests that the GNRI may serve as an effective screening tool for nutritional status in patients undergoing rTJA.

Concomitant malnutrition and frailty are significant risk factors for poor outcome following two-stage revision for chronic periprosthetic joint infection

BACKGROUND

Two-stage revision remains the gold standard for periprosthetic joint infection (PJI) treatment. Although previous studies have examined malnutrition and frailty independently, their cumulative effects are not clear. Therefore, this study aimed to assess the individual and combined influence of malnutrition and frailty on the two-stage revision surgery.

METHODS

Patients with chronic PJI undergoing two-stage revision were retrospectively included. The definition of PJI is completely consistent with the evidence-based definition of PJI recorded by the MSIS in 2018. Preoperative serum albumin levels and 11-item modified frailty index scores were collected. Four cohorts were created: (1) Normal (N), (2) Frail (F), (3) Malnourished (M), and (4) Malnourished and frail (MF). Demographic data, comorbidities, and postoperative complications were collected and compared between the four cohorts.

RESULTS

A total of 117 consecutive patients were enrolled, 48% of patients were healthy (27.4% F, 16.2% M, and 9.4% MF). MF group showed lower scores on the physical composite scale of the 12-item short-form health survey (SF12-PCS), mental composite summary (SF12-MCS), Harris hip score (HHS), and knee society score (KSS) (P < 0.05). The incidence of reinfection in the MF group was higher than that in all other groups (MF vs. N; odds ratio [OR] 3.7, 95% confidence interval [CI] 1.37 - 8.82, P = 0.032). The incidence of complications in the MF group was higher than that in all other groups (MF vs. N; OR 4.81, 95% CI 1.58-9.26, P = 0.018). Postoperative transfusion events (OR 2.92, 95% CI 1.27-3.09, P = 0.021), readmission at 60 days after the operation (OR 4.91, 95% CI 1.82-13.80, P = 0.012) was higher in the MF patients. In addition, the extended length of stay after the operation was highest in the MF patients, with an OR of 5.78 (95% CI 2.16-12.04, P = 0.003).

CONCLUSION

The concurrent presence of concomitant malnutrition and frailty in patients with PJI is related to poor prognosis and may be a predictor of the efficacy of two-stage revision. Future research will be needed to describe the benefits of improving these risk factors for patients with PJI.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care

Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.

Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty

Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.

Taking a Deeper Dive into Malnutrition and Revision Arthroplasty: When do Nutritionists Get Involved?

BACKGROUND

Perioperative malnutrition is associated with increased complications and mortality following revision total joint arthroplasty (TJA). Nutritional consultations are useful in characterizing patient nutritional status, but are inconsistently utilized post-revision TJA. We sought to describe 1) the prevalence of nutritional consultations post revision TJA, 2) determine if septic revision TJA patients needed consultations more often, and if 3) a diagnosis of 'malnutrition' from the nutritionist conferred increased readmission rates.

METHODS

A retrospective study of 2,697 rTJAs performed in a single institution over a 4-year period was performed. Patient demographics, reasons for revision TJA, occurrences of nutritional consultation (indicated if body mass index (BMI)<20, Malnutrition Screening Tool (MST) score > 2, or poor oral intake postoperatively), specific nutritional diagnosis (according to 2020 Electronic Nutrition Care Process Terminology (eNCPT) and 90-day readmission rates were recorded and analyzed. Rates of consultations and adjusted logistic regressions were calculated.

RESULTS

There were 501 patients (18.6%) who required nutritional consultations, with 55 (11.0%) of these patients receiving a 'malnutrition' diagnosis. Septic rTJA patients required significantly more nutritional consultations (P<0.01) and were significantly more likely to have 'malnutrition' (P=0.49). A diagnosis of malnutrition was associated with highest odds of all-cause readmission (Odds Ratio (OR)=3.89, P=0.01), which was even higher than undergoing a septic revision TJA.

CONCLUSION

Nutritional consultations occur frequently following revision TJA. Patients who receive a diagnosis of 'malnutrition' through consultation are at significantly higher risk for re-admission and require close follow-up. Future efforts are needed to further characterize these patients in order to identify as well as optimize them preoperatively.

Universal Screening for Malnutrition Prior to Total Knee Arthroplasty Is Cost-Effective: A Markov Analysis

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) who have malnutrition possess an increased risk of periprosthetic joint infection (PJI). Although malnutrition screening and intervention may decrease the risk of PJI, it utilizes healthcare resources. To date, no cost-effectiveness analyses have been performed on the screening and treatment of malnutrition prior to TKA.

METHODS

A Markov model projecting lifetime costs and quality-adjusted life years (QALYs) was built to determine the cost-effectiveness of malnutrition screening and intervention for TKA patients from a societal perspective. Costs, health state utilities, and state transition probabilities were obtained from previously published literature, hospital costs at our institution, and expert opinions. Two important assumptions included that 30% of patients would be malnourished and that a malnutrition intervention would be 50% effective. The primary outcome of this study was the incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000 per QALY. One-way and two-way sensitivity analyses were performed to evaluate model parameter assumptions.

RESULTS

When using the base case values, universal malnutrition screening and intervention was cost-effective compared to no malnutrition screening or intervention, with an incremental cost-effectiveness ratio of $6,454 per QALY. Universal screening and intervention remained cost-effective, provided the cost of screening remained less than $3,373, the cost of nutritional intervention remained less than $12,042, the prevalence of malnutrition among surgical candidates was higher than 2%, and the risk of PJI among patients with malnutrition was greater than 1%.

CONCLUSION

Universal preoperative malnutrition screening and intervention among TKA candidates is cost-effective at parameters encountered in clinical practice. Nutritional optimization programs should be considered to facilitate malnutrition screening and intervention and future studies should evaluate their efficacy at lowering PJI risk.

Underweight Patients are at Increased Risk for Complications following Total Hip Arthroplasty

BACKGROUND

Given the prevalence of obesity in the United States, much of the adult reconstruction literature focuses on the effects of obesity and morbid obesity. However, there is little published data on the effect of being underweight on postoperative outcomes. This study aimed to examine the risk of low body mass index (BMI) on complications after total hip arthroplasty (THA).

METHODS

A large national database was queried between 2010 and 2020 to identify patients who had THAs. Using International Classification of Disease codes, patients were grouped into the following BMI categories: morbid obesity (BMI>40), obesity (BMI 30 to 40), normal BMI (BMI 20 to 30), and underweight (BMI<20). There were 58,151 patients identified, including 2,484 (4.27%) underweight patients, 34,710 (59.69%) obese patients, and 20,957 (36.04%) morbidly obese patients. Control groups were created for each study group, matching for age, sex, and a comorbidity index. Complications that occurred within 1 year postoperatively were isolated. Subanalyses were performed to compare complications between underweight and obese patients. Statistical analyses were performed using Pearson Chi-squares.

RESULTS

Compared to their matched control group, underweight patients showed increased odds of THA revision (Odds Ratio (OR) = 1.32, P = .04), sepsis (OR = 1.51, P = .01), and periprosthetic fractures (OR = 1.63, P = .01). When directly comparing underweight and obese patients (BMI 30 and above), underweight patients had higher odds of aseptic loosening (OR = 1.62, P = .03), sepsis (OR = 1.34, P = .03), dislocation (OR = 1.84, P < .001), and periprosthetic fracture (OR = 1.46, P = .01).

CONCLUSION

Morbidly obese patients experience the highest odds of complications, although underweight patients also had elevated odds for several complications. Underweight patients are an under-recognized and understudied high risk arthroplasty cohort and further research is needed.

Nutritional Risk Screening 2002 predicts surgical outcomes in 1532 patients undergoing total joint arthroplasty: A retrospective cohort study

BACKGROUND

Limited information exists about the predictive effect of Nutritional Risk Screening (NRS) 2002 on orthopedic surgery. The aim of the present study is to explore the role of NRS 2002 in postoperative complications and resource utilization in patients with total joint arthroplasty (TJA).

METHODS

We retrospectively collected the demographics and surgical results of nearly 2000 TJA patients admitted from 2016 to 2020 and assessed the differences in short- and long-term complications and resource utilization parameters. Multivariate linear, logistic regression, and subgroup analysis were subsequently used to control for potential confounders. Survival analysis was performed to further verify the cumulative incidence of postoperative complications.

RESULTS

We identified 1532 patients receiving TJA, 8.7% of which were at nutrition risk (NRS 2002 score ≥3 out of 7). Preoperative nutrition risk was associated with an increased risk of systemic complications, incisional complications, surgical site infection (SSI), incisional SSI, periprosthetic joint infection, dislocation, and periprosthetic fracture after TJA (odds ratio [OR], 3.62-31.99; all P < 0.05). Preoperative nutrition risk was further associated with an increased risk of cardiac complications, respiratory complications, urinary complications, and arthroplasty-related reoperation (OR, 3.16-12.29; all P < 0.01). Moreover, preoperative nutrition risk was associated with increased costs and length of stay, and increased risk of unplanned intensive care unit admission, arthroplasty-related readmission, infection-related readmission, and SSI-related readmission.

CONCLUSIONS

NRS 2002 is associated with an elevated risk of postoperative complications and increased resource utilization, following TJA. Thus, routine screening is recommended to identify nutrition risk statuses of patients undergoing elective TJA.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients

BACKGROUND

Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA.

METHODS

The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes.

RESULTS

A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m²), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05).

CONCLUSION

Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately.

LEVEL OF EVIDENCE

Level 3: Retrospective Cohort Study.

Pedicled vastus lateralis myocutaneous flap for sacropelvic defects after wide oncologic resection: Wound complications and outcomes

BACKGROUND AND OBJECTIVES

Adequate coverage of the soft tissue defects from wide resection of sacropelvic malignancies remains challenging. The vastus lateralis flap has been described for coverage in the setting of trauma and infection. This flap has not been described for coverage of sacropelvic tumor defects.

METHODS

This is a retrospective cohort study of adult patients who underwent wide resection of a primary sacropelvic malignancy with reconstruction employing a pedicled vastus lateralis flap at two tertiary care centers. Patient demographics, tumor staging, and rate of complications were assessed.

RESULTS

Twenty-eight patients were included, with a median age of 51 years. The most common primary tumor was chondrosarcoma followed by chondroblastic osteosarcoma. The median follow-up was 1.1 years. There were 10 cases of wound infection requiring re-operation and three cases of flap failure.

CONCLUSIONS

We describe a pedicled vastus lateralis flap for coverage of defects after wide resection of sacropelvic malignancies. A large proportion of our cohort had independent risk factors for wound complications. Even with a cohort with high baseline risk for wound complications, we show that the use of a pedicled vastus lateralis flap is a safe reconstructive option with a wound complication rate in line with the literature.

Emergency department visits following total joint arthroplasty: do revisions present a higher burden?

Aims

Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits.

Methods

We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables.

Results

Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001).

Conclusion

ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA.

Cite this article: Bone Jt Open 2022;3(7):543–548.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge

BACKGROUND

Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations.

METHODS

We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables.

RESULTS

Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131).

CONCLUSION

Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: a Detailed Review and Guide to Management

PURPOSE OF REVIEW

8.5 to 50% of total joint arthroplasty (TJA) patients are reported to have preoperative malnutrition. The narrative review identifies the relationship between preoperative malnutrition for TJA patients and postoperative outcomes as well as the use of perioperative nutritional intervention to improve postoperative complications.

RECENT FINDINGS

Biochemical/laboratory, anthropometric, and clinical measures have been widely used to identify preoperative nutritional deficiency. Specifically, serum albumin is the most prevalent used marker in TJA because it has been proven to be correlated with protein-energy malnutrition due to the surgical stress response. However, there remains a sustained incidence of preoperative malnutrition in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients due to a lack of agreement among the available nutritional screening tools and utilization of isolated laboratory, anthropometric, and clinical variables. Previous investigations have also suggested preoperative malnutrition to be a prognostic indicator of complications in general, cardiac, vascular, and orthopaedic surgery specialties. Serum albumin, prealbumin, transferrin, and total lymphocyte count (TLC) can be used to identify at-risk patients. It is important to employ these markers in the preoperative setting because malnourished TKA and THA patients have shown to have worse postoperative outcomes including prolonged length, increased reoperation rates, increased infection rates, and increased mortality rates. Although benefits from high-protein and high-anti-inflammatory diets have been exhibited, additional research is needed to confirm the use of perioperative nutritional intervention as an appropriate treatment for preoperative TJA patients.

Team Approach: Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty

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Nutritional assessment is a critical element of routine preoperative assessment and should be approached by an interdisciplinary team that involves the primary care physician, dietitian, and orthopaedist.

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Patients should be stratified on the basis of their nutritional risk, which influences downstream optimization and deficiency reversal.

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The scientific literature indicates that nutritional supplementation affords protection against adverse outcomes and helps functional recovery, even among patients who are not at nutritional risk.

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Published investigations recommend a sufficient preoperative interval (at least 4 weeks) to ensure an adequate nutritional intervention in malnourished patients as opposed to regarding them as nonsurgical candidates.

Nutritional and Physical Prehabilitation in Elective Orthopedic Surgery: Rationale and Proposal for Implementation

In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient’s risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.

Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty

Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes

BACKGROUND

Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

METHODS

All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

RESULTS

The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

CONCLUSION

Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.

Development of a Novel, Potentially Universal Machine Learning Algorithm for Prediction of Complications After Total Hip Arthroplasty

BACKGROUND

As the prevalence of hip osteoarthritis increases, the number of total hip arthroplasty (THA) procedures performed is also projected to increase. Accurately risk-stratifying patients who undergo THA would be of great utility, given the significant cost and morbidity associated with developing perioperative complications. We aim to develop a novel machine learning (ML)-based ensemble algorithm for the prediction of major complications after THA, as well as compare its performance against standard benchmark ML methods.

METHODS

This is a retrospective cohort study of 89,986 adults who underwent primary THA at any California-licensed hospital between 2015 and 2017. The primary outcome was major complications (eg infection, venous thromboembolism, cardiac complication, pulmonary complication). We developed a model predicting complication risk using AutoPrognosis, an automated ML framework that configures the optimally performing ensemble of ML-based prognostic models. We compared our model with logistic regression and standard benchmark ML models, assessing discrimination and calibration.

RESULTS

There were 545 patients who had major complications (0.61%). Our novel algorithm was well-calibrated and improved risk prediction compared to logistic regression, as well as outperformed the other four standard benchmark ML algorithms. The variables most important for AutoPrognosis (eg malnutrition, dementia, cancer) differ from those that are most important for logistic regression (eg chronic atherosclerosis, renal failure, chronic obstructive pulmonary disease).

CONCLUSION

We report a novel ensemble ML algorithm for the prediction of major complications after THA. It demonstrates superior risk prediction compared to logistic regression and other standard ML benchmark algorithms. By providing accurate prognostic information, this algorithm may facilitate more informed preoperative shared decision-making.