Complications and Readmission Incidence Following Total Hip Arthroplasty in Patients Who Have End-Stage Renal Failure

Total Hip Arthroplasty Outcomes before or after Renal Transplant: A Retrospective Large Cohort Analysis

Background

While it is known that patients with end-stage renal disease (ESRD) are at an increased risk of complications following total hip arthroplasty (THA), there is a gap in the literature in comparing patients with ESRD to patients who undergo renal transplant (RT) before or after THA. This study is to address this gap by analyzing outcomes of THA in ESRD patients, RT patients, and RT candidates.

Methods

Using the PearlDiver Mariner database, ESRD patients, RT patients, and RT candidates undergoing primary THA were identified and compared. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. Ninety-day emergency department (ED) visits and inpatient readmission were also documented.

Results

A total of 7,868 patients were included: 5,092 had ESRD, 2,520 had RT before THA, and 256 were candidates for RT. Compared to patients with ESRD, RT patients demonstrated lower rates of medical complications such as pneumonia (3.61% vs. 5.99%, p = 0.039) and transfusion (4.60% vs. 7.66%, p < 0.001). Additionally, RT patients displayed decreased rates of surgical complications, including wound complications (2.70% vs. 4.22%, p = 0.001), periprosthetic joint infection (PJI) at 1 year (2.30% vs. 4.81%, p < 0.001) and 2 years (2.58% vs. 5.42%, p < 0.001), and aseptic loosening at 2 years (0.79% vs. 1.43%, p = 0.006). Similarly, when compared to RT candidates, RT patients demonstrated a lower incidence of postoperative complications, including 1-year PJI (2.30% vs. 5.08%, p = 0.013), 2-year PJI (2.58% vs. 5.08%, p = 0.028), 1-year aseptic loosening (0.56% vs. 2.73%, p < 0.001), and 2-year aseptic loosening (0.79% vs. 2.73%, p = 0.005). RT patients also had lower rates of ED visits and hospital readmissions.

Conclusions

Compared to ESRD patients and RT candidates, patients with RT have a significantly lower likelihood of medical complications, PJI, aseptic hardware loosening, ED visits, and hospital readmission. Patients with ESRD on the RT waiting list should delay THA until after RT surgery. For those not eligible for RT, it is vital to take extra precautions to reduce the risk of complications.

End-stage renal disease patients have comparable results to renal transplant patients after shoulder arthroplasty

Background

End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA.

Methods

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points.

Results

Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts.

Conclusion

SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Primary Total Hip Arthroplasty in Dialysis-Dependent Patients: 35% Mortality at 5 years

BACKGROUND

Limited knowledge exists on contemporary results of primary total hip arthroplasty (THA) in dialysis-dependent patients. We sought to analyze the mortality rates and cumulative incidences of any revision or reoperation in dialysis-dependent patients undergoing primary THAs.

METHODS

We identified 24 dialysis-dependent patients who underwent 28 primary THAs between 2000 and 2019 using our institutional total joint registry. Mean age was 57 years (range, 32 to 86), with 43% being women and mean body mass index was 31 (range, 20 to 50). The leading cause for dialysis was diabetic nephropathy (18%). The mean preoperative creatinine and glomerular filtration rate were 6 mg/dL and 13 mL/min, respectively. Kaplan-Meier survivorship methods and a competing risk analysis using death as the competing risk were performed. The mean follow-up was 7 years (range, 2 to 15).

RESULTS

The 5-year survivorship free from death was 65%. The 5-year cumulative incidence of any revision was 8%. There were a total of 3 revisions as follows: 2 for aseptic loosening of the femoral component and one for a Vancouver B2 fracture. The 5-year cumulative incidence of any reoperation was 19%. There were 3 additional reoperations, and all were irrigation and debridement. Postoperative creatinine and glomerular filtration rate were 6 mg/dL and 15 mL/min, respectively. At a mean of 2 years after THA, 25% successfully received a renal transplant.

CONCLUSIONS

Dialysis-dependent patients undergoing primary THAs had high 5-year mortality (35%) but an acceptably low cumulative incidence of any revision. While renal metrics remained consistent after THA, only one in 4 patients underwent successful renal transplant.

LEVEL OF EVIDENCE

IV.

Knee and hip arthroplasty joint surgical site wound infection in end-stage renal disease subjects who underwent dialysis or a kidney transplant: A meta-analysis

A meta-analysis study to assess the knee and hip arthroplasty joint surgical site wound infection (SSWI) in end-stage renal disease (ESRD) subjects who underwent dialysis or a kidney transplant (KT). A comprehensive literature examination till February 2023 was implemented and 1046 linked studies were appraised. The picked studies contained 5 471 898 subjects with total joint arthroplasty (TJA) at the baseline, 13 049 of them were haemodialysis or renal transplant, and 5 458 849 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of knee and hip arthroplasty SSWI in ESRD subjects who underwent dialysis or a KT by the dichotomous and continuous styles and a fixed or random model. Haemodialysis or renal transplant had a significantly higher postoperative SSWI (OR, 2.13; 95% CI, 1.73-2.62, P < .001) compared with control in TJA subjects. However, no significant difference was observed between haemodialysis and renal transplant in postoperative SSWI (OR, 0.93; 95% CI, 0.16-5.54, P = .94) and between haemodialysis or renal transplant and control in prosthetic joint infection (OR, 1.07; 95% CI, 0.25-4.55, P = .93) in TJA subjects. Haemodialysis had a significantly higher prosthetic joint infection (OR, 1.92; 95% CI, 1.21-3.03, P = .005) compared with renal transplant in TJA subjects. Haemodialysis or renal transplant had a significantly higher postoperative SSWI in TJA subjects. Also, haemodialysis had a significantly higher prosthetic joint infection compared with renal transplant in TJA subjects. Although precautions should be taken when commerce with the consequences because a low number of selected studies was picked for certain comparisons in this meta-analysis.

Total hip arthroplasty complications in patients with chronic kidney disease: A comparison study

Background

It has been noted in the literature that there are increased complication rates following total hip arthroplasty (THA) in patients with chronic kidney disease (CKD) or end stage renal disease (ESRD). However, there is little data directly comparing outcomes in patients undergoing THA for osteoarthritis (OA) versus ESRD or CKD with OA. The objective of this study is to illustrate the risk of developing postoperative complications after THA in the CKD and ESRD populations by stage of disease when compared to a control group (OA) and thus better equip orthopaedic providers in the care of these patients.

Methods

The National Inpatient Sample (NIS) was utilized to identify patients undergoing elective THA from 2006 to 2015 with OA, ESRD, and CKD. The prevalence of preoperative comorbidities and the incidence of numerous postoperative complications broken into categories were examined.

Results

Between 2006 and 2015 the NIS database reported 4,350,961 patients diagnosed with OA, 8355 diagnosed with ESRD, and 104,313 diagnosed with CKD undergoing THA. The incidence of wound hematoma (2.5% vs. 0.8%; p < .0001), wound infection (0.7% vs. 0.4%; p = .0319), cardiac (1.3% vs. 0.6%; p = .0067), urinary (3.9% vs. 2.0%; p < .0001), and pulmonary complications (2.2% vs. 0.5%; p < .0001) occurred more frequently in patients with OA and ESRD when compared to only OA patients. For patients with OA and CKD, stages 3-5 saw at least half of the complication categories occur at significantly higher rates than OA patients.

Conclusion

This study shows that patients with ESRD and CKD have increased rates of complications after THA. This study's specific breakdown by stage and complication can benefit orthopaedic surgeons and practitioners in realistic pre and postoperative planning and provides data that could benefit decision making on bundled reimbursement for this specific patient population, as providers could better account for the postoperative complications noted above and their associated costs.

Dialysis Patients Undergoing Total Hip Arthroplasty have Higher Rates of Morbidity and Mortality and Incur Greater Healthcare Costs: A National Database Study from 367,894 Patients

Purpose

The incidence of a total hip arthroplasty (THA) is sevenfold higher in dialysed patients. Only a few have specifically studied the impact of chronic dialysis on outcomes of THA whilst comparing them with non-dialysed/controls. The present study questioned whether significant differences existed in morbidity and mortality rates after THA in dialysed and non-dialysed patients.

Methods

The National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project using records for THAs performed during 2016-2019 was employed. This largest, nationwide, in-patient database in the US acquires data from > 7 million hospital stays annually from > 20% hospitals. Among 367,894 THAs performed during 2016-2019, 383 were regularly dialysed. The two groups (dialysis and controls) were compared for in-hospital mortality, demographic data, perioperative details and medical/surgical complications.

Results

Dialysed patients were younger (p < 0.001), had greater mortality (0.5% vs 0.09%, p = 0.005), lengths of stay (4.4 vs 2.3 days, p < 0.001), costs ($96,824 vs $66,848, p < 0.001) and male preponderance (p < 0.001). Postoperative dislocations (3.1% vs 1.4%, p = 0.013), mechanical complications (p = 0.032) and blood loss (p = 0.031) were greater in dialysed patients. Medical postoperative complications (myocardial infarction, pneumonia, thromboembolism, acute renal failure), periprosthetic fractures, wound dehiscence, superficial and deep surgical-site infection and periprosthetic joint infections were comparable between the 2 groups. Dialysed patients had elective THAs more often (25% vs 8.6%). Controls had higher (twofold) home discharges while ~ 50% of dialysed THAs needed discharge to another facility.

Conclusions

This large national data highlighted greater morbidity and mortality among dialysis patients following THA, something to consider preoperatively along with individual circumstances whilst making risk-benefit assessments for arthroplasty. Improvements in healthcare could bridge gaps between outcomes and expectations in dialysed patients.

Hip Arthroplasty Outcomes in the Presence of Kidney Failure: A National Data Linkage Study

BACKGROUND

Patients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure.

METHODS

A data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529).

RESULTS

There was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25).

CONCLUSION

The rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery.

Neighborhood Socioeconomic Disadvantage Associated With Increased Healthcare Utilization After Total Hip Arthroplasty

BACKGROUND

The multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions.

METHODS

Two thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (>3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios.

RESULTS

In the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P < .001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001).

CONCLUSIONS

Higher ADI is associated with an increased healthcare utilization within 90 days of THA.

Clinical Outcomes following Primary Hip Replacement Arthroplasties in Patients with Solid Organ Transplantation: A Systematic Review and Meta-Analysis

There is still controversy regarding clinical outcomes following primary hip arthroplasty after solid organ transplantation (SOT). The aim of this study was to determine whether clinical outcomes after hip arthroplasty differ between previous SOT recipients and control subjects with no history of undergoing SOT. We conducted a systematic search of MEDLINE, Embase, and the Cochrane Library for studies comparing the clinical outcomes after hip arthroplasty following SOT published up to January 5, 2022. A comparison of medical and surgery-related complications, as well as the readmission rate and 90-day mortality rate between previous SOT recipients and control subjects was performed. Subgroup analyses of the SOT types, liver transplantation (LT) and kidney transplantation (KT), were also performed. Ten studies that included 3,631,861 cases of primary hip arthroplasty were included; among these, 14,996 patients had previously undergone SOT and 3,616,865 patients had not. Significantly higher incidences of cardiac complications, pneumonia, and acute kidney injury were observed in the SOT group compared with the control group. Regarding surgical complications, a higher transfusion rate was observed in the SOT group. The readmission rate and 90-day mortality rate were also significantly higher in the SOT group. A significantly higher incidence of deep vein thrombosis was observed in the KT subgroup compared with the control group. A higher risk of medical and surgical complications, as well as higher readmission and mortality rates after hip arthroplasty was observed for previous SOT recipients compared to patients with no history of SOT.

Comparison of total hip arthroplasty outcomes between hemodialysis and renal transplant patients

INTRODUCTION

Total hip arthroplasty (THA) in end-stage renal disease (ESRD) patients is associated with increased complications. Controversy exists whether elective THA should be performed while these patients are on haemodialysis (HD) or following renal transplant (RT). This study seeks to compare THA outcomes in HD versus RT patients.

METHODS

A national database was retrospectively reviewed using ICD codes to identify all HD and RT patients who underwent primary THA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared between cohorts using Wald and chi-square tests. The primary outcome was in-hospital mortality, while secondary outcomes included length of stay (LOS), non-home discharge, cost, readmission, and medical/surgical complications. Multivariate regression was used to determine independent associations. Significance was determined with a 2-tailed p-value of 0.05.

RESULTS

11,133 patients underwent THA, 61.6% HD and 39.4% RT patients. RT patients were younger, had fewer comorbidities, and more likely to have private insurance. After adjusting for these differences, RT patients had a lower rate of mortality (OR 0.31, p = 0.01), complications (OR 0.54, p < 0.01), cardiopulmonary complications (OR 0.54, p = 0.04), sepsis (OR 0.43, p < 0.01), and blood transfusion (OR 0.39, p < 0.001) during the index hospitalisation. RT was associated with decreased LOS (-2.0 days, p < 0.001), non-home discharge (OR 0.35, p < 0.001), and hospital cost (-$6,000, p < 0.001). RT had a lower rate of readmission (OR 0.60, p < 0.001) and revision surgery (OR 0.24, p = 0.01) within 90 days.

CONCLUSIONS

These findings suggest HD patients are a high-risk population in THA compared to RT patients and warrant stringent perioperative monitoring.

Outcomes Following Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients on Hemodialysis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients on hemodialysis (HD) are at increased risk for complications after THA for osteoarthritis, however there is limited information on outcomes of THA for ONFH in patients on HD. With increasing prevalence of chronic kidney disease (CKD) requiring HD, studies are needed to characterize the risk of complications in these patients. Therefore, the purpose of this study was to evaluate HD as a potential risk factor for complication after THA in patients with ONFH on HD.

METHODS

Patients on HD with ONFH who underwent THA with at least 2 years of follow-up were identified using a combination of ICD-9 and CPT codes in a national insurance database. A 10:1 matched control cohort of patients with ONFH not on HD was created for comparison. A logistic regression analysis was used to evaluate rates of death, hospital readmission, emergency room (ER) visit, infection, revision, and dislocation between cohorts. Differences in hospital charges, reimbursement, and length of stay between the two groups were also assessed.

RESULTS

One thousand one hundred thirty-seven patients on HD who underwent THA for ONFH were compared to a matched control cohort of 11,182 non-HD patients who underwent THA for ONFH. Patients on HD experienced higher rates of death (HD 4.1%, non-HD 0.9%; odds ratio [OR] 3.35, p < 0.01), hospital readmission (HD 16.1%, non-HD 5.9%; OR 2.69, p < 0.01) and ER visit (HD 10.4%, non-HD 7.4% OR 1.5, p < 0.01). Hemodialysis was not associated with higher risk of infection, revision, or dislocation, but was associated with significantly higher charges (p < 0.01), reimbursement (p < 0.01), and hospital length of stay (p < 0.01).

CONCLUSIONS

While patients on HD do not have increased risk of implant-related complications, they are at increased risk of developing medical complications following THA for ONFH and subsequently may require more resources. Orthopedic surgeons and nephrologists should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

LEVEL OF EVIDENCE

Therapeutic Level III.

Mid-term clinical outcomes and complications of primary total knee arthroplasty in hemodialysis patients: a retrospective comparative cohort study

Background

Numerous patients who receive hemodialysis (HD) undergo total knee arthroplasty (TKA) due to advanced knee joint arthritis. However, there are few studies that describe the clinical outcomes and complications of TKA in HD patients. This study investigated the mid-term results of TKA in patients undergoing HD.

Methods

This single-center retrospective study compared clinical and surgical outcomes following TKA in patients who were receiving HD with those who were not. We used propensity scores to match 21 knees of 18 patients who received HD to 706 knees of 569 patients who had not received HD, from a total of 727 knees (587 patients) that underwent primary unilateral TKA. The clinical outcomes were evaluated using the American Knee Society Score-knee (AKSS-knee) and AKSS-function scores. The primary surgical outcome measure was the number of knees with postoperative complications.

Results

In both the HD and non-HD groups, postoperative AKSS-knee and function scores significantly improved when compared to preoperative values. Postoperative AKSS-knee and function scores were not significantly different between the groups. The number of knees with postoperative complications was larger in the HD group than the non-HD group within the first postoperative month, 0–12 months, 12–24 months, 0–24 months, and two years after surgery. Additionally, in the HD group, more complications occurred in the first month than any subsequent month in the two years after surgery.

Conclusions

TKA improves AKSS-knee and function scores equivalently for HD patients and non-HD patients. However, HD patients develop more complications after TKA, especially within the first month. Therefore, surgeons who perform TKA for HD patients should obtain informed consent after explaining the possible complications, and HD patients should be carefully observed following TKA.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.

Hydroxyapatite-coated cementless total hip arthroplasty for patients undergoing dialysis: a study of 30 hips with a minimum follow-up period of 5 years

Background

The number of total hip arthroplasties (THAs) performed for patients undergoing dialysis is increasing. However, there are few reports of cementless THA for patients undergoing dialysis. This study investigated the mid-term to long-term results of hydroxyapatite (HA)-coated cementless THA for dialysis patients.

Methods

This single-center, retrospective study enrolled dialysis patients undergoing primary HA-coated cementless THA. A total of 24 patients (30 hips) were included in the final analyses. The Harris hip score and radiographic results were assessed preoperatively and during the final follow-up examination. Postoperative complications and mortality rates were recorded. The mean follow-up period was 109 months (range, 60–216 months).

Results

The total Harris hip score significantly improved from 40 to 84 points. The overall cumulative survival rates with revision as the endpoint were 100% at 5 years and 90.4% at both 10 and 15 years. Stress shielding was observed in 24 hips (80%). No deaths were related to the primary THA. Complications included periprosthetic fracture for one patient (3.3%), blood transfusion for nine patients (30%), shunt blockage for two patients (6.7%), deep infection for one patient (3.3%), and dislocation for two patients (6.7%).

Conclusions

HA-coated cementless THA resulted in good mid-term outcomes for patients undergoing dialysis with no mortality risk. However, the procedure involved a relatively high perioperative risk of blood transfusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04718-3.

Dialysis patients have comparable results to patients who have received kidney transplant after total joint arthroplasty: a systematic review and meta-analysis

Patients with end-stage renal disease (ESRD) have inferior outcomes after hip and knee total joint arthroplasty (TJA), with higher risk for surgical site complications (SSC) and periprosthetic joint infection (PJI).

We conducted a systematic review and meta-analysis regarding outcomes after hip and knee TJA in ESRD patients who have received dialysis or a kidney transplant (KT) using PubMed, MEDLINE, Cochrane Reviews, and Embase in order to: (1) determine the mortality and infection rate of TJA in patients receiving dialysis or KT and (2) to identify risk factors associated with the outcome.

We included 22 studies and 9384 patients (dialysis, n = 8921, KT, n = 463). The overall mortality rate was 14.9% and was slightly higher in KT patients (dialysis vs. KT, 13.8% vs. 15.8%). The overall SSC rate was 3.4%, while dialysis and KT patients each had an incidence of 3.3% and 3.6%, respectively. For PJI, the overall rate was 3.9%, while the incidence for dialysis patients was 4.0% and for KT patients was 3.7%.

Using multi-regression analysis, age, sex, the type of arthroplasty (knee or hip) performed, and the form of renal replacement therapy (dialysis or KT) were not significant risk factors.

In patients on dialysis or who had received a KT, TJA is associated with a slight increase in mortality, SSC and PJI rates.

Cite this article: EFORT Open Rev 2021;6:618-628. DOI: 10.1302/2058-5241.6.200116

Comparing Primary Total Hip Arthroplasty in Renal Transplant Recipients to Patients on Dialysis for End-Stage Renal Disease: A Nationally Matched Analysis

BACKGROUND

Renal transplants are the most commonly performed solid-organ transplants worldwide. It is unclear whether a kidney transplant is associated with reduced postoperative complications in comparison with patients on dialysis for end-stage renal disease (ESRD). The purpose of this study was to utilize a national database to compare readmissions, complications, and costs associated with primary total hip arthroplasty (THA) between matched renal transplant recipients (RTRs) and patients on dialysis for ESRD.

METHODS

Patients with a renal transplant (N = 1,401) and those on dialysis for ESRD (without a transplant) (N = 1,463) prior to being treated with a THA from 2010 to 2019 were identified within the PearlDiver database. RTRs and patients on renal dialysis were frequency-matched 1:1 on the basis of 9 patient characteristics, resulting in 582 patients in each group. Length of hospital stay, readmissions, complication rates up to 2 years, and total costs up to 1 year were compared between the groups using chi-square and multivariable logistic regression analyses to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Patients on renal dialysis had an increased mean length of stay (6.3 days) compared with RTRs (4.6 days, p < 0.01). After adjusting for age, tobacco use, and diabetes, patients on renal dialysis were more likely to be readmitted by 90 days (OR = 1.59; CI = 1.11 to 2.29, p < 0.01) and have mechanical complications (OR = 2.13; CI = 1.08 to 4.45, p = 0.03) and revisions (OR = 2.14; CI = 1.14 to 4.01, p = 0.01) by 2 years. Patients on renal dialysis were also more likely to have periprosthetic joint infections at 1 year (OR = 1.91; CI = 1.02 to 3.71, p = 0.04). Patients on dialysis incurred 14% higher costs at 1 year (p = 0.11).

CONCLUSIONS

Patients on renal dialysis had more readmissions, complications, and costs after THA when compared with RTRs. Specifically, patients on renal dialysis were more likely to have longer index lengths of stay, more readmissions by 90 days, and more mechanical complications and revision surgery by 2 years. Patients on dialysis also incurred higher costs and had greater odds of PJI. These results suggest that joint surgeons may consider delaying THA in suitable patients until after renal transplantation to reduce postoperative complications and costs.

LEVEL OF EVIDENCE

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

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.

Serum Raman spectroscopy combined with multiple algorithms for diagnosing thyroid dysfunction and chronic renal failure

In this study, 60 samples taken from patients with thyroid dysfunction, 40 samples taken from patients with chronic renal failure (CRF) and 60 samples taken from healthy people were classified. We used partial least squares (PLS) to extract features to reduce the dimension of the spectral data to discriminate among the different samples. The Decision Trees (DT), Extreme Learning Machine (ELM), Probabilistic Neural Network (PNN), Back Propagation Neural Network (BPNN) and Learning Vector Quantization (LVQ) algorithms were used to build classification models and compare the results. The PLS-PNN algorithm distinguished between patients with thyroid dysfunction and patients with chronic renal failure with up to a 96.67 % accuracy rate, the PLS-BP algorithm distinguished between patients with chronic renal failure and healthy people with up to a 98.33 % accuracy rate, and the PLS-PNN algorithm and the PLS-DT algorithm distinguished between healthy people and patients with chronic renal failure with up to a 100 % accuracy rate. The results showed that serum Raman spectroscopy can be used in conjunction with classification algorithms to rapidly and accurately diagnose and distinguish between thyroid dysfunction and chronic renal failure.

Comparison of total joint arthroplasty outcomes between renal transplant patients and dialysis patients-a meta-analysis and systematic review

OBJECTIVES

End-stage renal disease (ESRD) patients are at an increased risk of needing total joint arthroplasty (TJA); however, both dialysis and renal transplantation might be potential predictors of adverse TJA outcomes. For dialysis patients, the high risk of blood-borne infection and impaired muscular skeletal function are threats to implants' survival, while for renal transplant patients, immunosuppression therapy is also a concern. There is still no high-level evidence in the published literature that has determined the best timing of TJA for ESRD patients.

METHODS

A literature search in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to November 2019) was performed to collect studies comparing TJA outcomes between renal transplant and dialysis patients. Two reviewers independently conducted literature screening and quality assessments with the Newcastle-Ottawa Scale (NOS). After the data were extracted, statistical analyses were performed.

RESULTS

Compared with the dialysis group, a lower risk of mortality (RR = 0.56, Cl = [0.42, 0.73], P < 0.01, I² = 49%) and revision (RR = 0.42, CI = [0.30, 0.59], P < 0.01, I² = 43%) was detected in the renal transplant group. Different results of periprosthetic joint infection were shown in subgroups with different sample sizes. There was no significant difference in periprosthetic joint infection in the small-sample-size subgroup, while in the large-sample-size subgroup, renal transplant patients had significantly less risk (RR = 0.19, CI = [0.13, 0.23], P < 0.01, I² = 0%). For dislocation, venous thromboembolic disease, and overall complications, there was no significant difference between the two groups.

CONCLUSION

Total joint arthroplasty has better safety and outcomes in renal transplant patients than in dialysis patients. Therefore, delaying total joint arthroplasty in dialysis patients until renal transplantation has been performed would be a desirable option. The controversy among different studies might be partially accounted for that quite a few studies have a relatively small sample size to detect the difference between renal transplant patients and dialysis patients.