The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States

Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review

Solid organ transplants (SOT) have evolved into life-saving interventions for end-stage diseases affecting vital organs. Advances in transplantation techniques, donor selection, and immunosuppressive therapies have enhanced outcomes, leading to a growing demand for SOT. Patients with a solid organ transplant are living long enough to develop the same pathologies which are indicated for joint replacement surgery in the general population. SOT patients who undergo a total hip, knee, or shoulder arthroplasty do similarly in the context of clinical outcomes and implant survival when compared to the general population. These immunosuppressed patients tend to have higher complication rates in the short-term following surgery. Prudent management of these patients in the short-term may be necessary, but patients can expect to do well otherwise.

The Influence of Solid Organ Transplant on Inpatient Complications, Length of Stay, and Hospital Costs in Reverse Shoulder Arthroplasty Patients

INTRODUCTION

With innovations in transplant medicine and longer life expectancies in solid organ transplant (SOT) recipients, the incidence of shoulder arthroplasty is predictably rising in this population. Reverse shoulder arthroplasty (RSA) has become increasingly popular due to advances in prosthetic design with expanded indications. While previous studies have examined shoulder arthroplasty in SOT patients, information specifically related to RSA patients is largely unexplored. We aim to analyze the demographics and characteristics of SOT patients who have undergone RSA while assessing inpatient complication rates, length of stay (LOS), and hospital costs in these patients compared to a matched cohort of non-transplant patients.

METHODS

The National Inpatient Sample (NIS) Database was utilized to identify all patients undergoing RSA from 2016 to 2019. We generated propensity-matched groups based on pre-operative variables (diabetes, tobacco use, sex, age, and obesity) to compare complications, LOS, and inpatient costs between the SOT and control groups. T-tests and Chi-squared tests were performed where appropriate and odds ratios were calculated.

RESULTS

We identified 59925 patients who underwent RSA. Among those, 59769 patients (99.7%) did not have a SOT and 156 patients (0.26%) had a history of SOT. Patients in the SOT group were younger than the control group (67.0 versus 71.4 years, p<0.001). The SOT group were more likely males compared to the control group (53.8% versus 39.3%, p<0.001). Following 1:1 matching, there were 156 patients in each group. The SOT group had a higher risk of acute renal failure (ARF) compared to the control group (OR 9.41, 95% CI (2.13-41.49), p<0.001). The LOS (p<0.001) and inpatient costs (p<0.001) were higher in the SOT group.

CONCLUSION

For RSA, SOT patients are younger and more likely male compared to those without SOT. Inpatient medical and surgical complications are similar between SOT and non-SOT patients, except SOT patients have a higher risk of ARF. SOT patients tend to have longer LOS and higher inpatient costs than non-SOT patients.

Incidence and risk factors of in-hospital prosthesis-related complications following total shoulder arthroplasty

BACKGROUND

The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database.

METHODS

A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated.

RESULTS

A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion.

CONCLUSIONS

It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

Identification of Independent Predictors of Increased 90-Day Complication and Revision Rates Following Total Elbow Arthroplasty

Introduction

Total elbow arthroplasty (TEA) is an increasingly popular surgical option for many debilitating conditions of the elbow. There currently exists a paucity of literature regarding patient and hospital factors that lead to inferior outcomes following TEA. The purpose of this study is to identify independent predictors of increased complication and revision rates following TEA.

Methods

The National Readmissions Database (NRD) was queried from 2011 to 2018 to identify all cases of TEA (n = 8932). Relevant patient demographic factors, comorbidities, and hospital characteristics were identified and run in a univariate binomial logistic regression model. All significant variables were included in a multivariate binomial logistic regression model for data analysis.

Results

Independent predictors of increased complication rates included age, female sex, Medicare and Medicaid payer status, medium bed-sized center, and 18 of 34 medical comorbidities (all P < .05). Independent predictors of increased revision rates included medium bed-sized centers, non-teaching hospital status, chronic pulmonary disease, depression, and pulmonary circulatory disorders (all P < .05).

Conclusion

This study identified several patient and hospital characteristics that are independently associated with both increased complication and revision rates following TEA. This information can aid orthopedic surgeons during shared decision making when considering TEA in patients.

Level of Evidence

Level III, retrospective cohort study.

Shoulder arthroplasty following solid organ transplant: A systematic review and meta-analysis

Introduction

The purpose of this study is to report a systematic review and meta-analysis of solid organ transplant (SOT) patients undergoing shoulder arthroplasty to compare functional and radiographic outcomes, demographics, and complications with non-transplant patients.

Methods

Studies were included if they examined patients undergoing shoulder arthroplasty in the setting of prior solid organ transplantation and included post operative range of motion, patient-reported outcomes, complications, or revisions. Studies were excluded if they were national database analyses or lacked clinical data. Pubmed, MEDLine, Scopus, and Web of Science were queried using relevant search terms in July 2022. Data was pooled, weighted, and a paired t-test and chi-square analysis was performed.

Results

There were 71 SOT and 159 non-SOT shoulders included in the study. The most common indication for surgery was avascular necrosis (n = 26) in the solid organ transplant group and osteoarthritis (n = 60) in the non-SOT group. Forward elevation, external rotation, ASES, and VAS pain scores improved significantly in both cohorts following surgery. There was no significant difference in age at surgery (p-value = 0.20), postoperative forward elevation (p-value = 0.08), postoperative external rotation (0.84), and postoperative ASES scores (p-value = 0.11) between the two cohorts. VAS pain scores were significantly lower in the SOT cohort (p-value<0.01). The risk of death was significantly higher in the SOT group (p-value<0.01). but the rate of overall complications (p = 0.47), surgical complication (p-value = 0.79), or revision surgery (p-value = 1.00) was not significantly different between the two cohorts.

Conclusion

Shoulder arthroplasty is a safe, effective option in patients following solid organ transplant. There is not an increased risk of adverse outcomes, and SOT patients had comparable range of motion and patient-reported outcomes when compared to their non-SOT peers.

Level of evidence

III.

Complications, demographics and hospital stay in organ transplant patients undergoing total hip arthroplasty - A national database study between 2016 and 2019

Background

The purpose of this study was to analyze the post-operative complications following THA in organ transplant patients; and compare the outcome with general population undergoing THA.

Methods and materials

In this retrospective study using the National Inpatient Sample (NIS) database, 813 cases of THA (both primary and revision THA) in organ transplant patients (OT) were reviewed. ICD-10 codes were used to assess post-operative variables including the length of stay, cost of care, medical and surgical complications among OT patients undergoing THA. A comparison of all these variables was made with the non-OT (NOT) control population.

Results

Among 367,894 patients undergoing THR between 2016 and 2019 on NIS database, 813 were OT patients. There was significantly greater proportion of males in the OT group (p < 0.001). Patients in the OT group were also significantly younger (mean age: 61.08 ± 11.95 in OT versus 65.87 ± 11.39 years in NOT; p < 0.001). The OT group had significantly higher prevalence of anemia (p < 0.001), acute renal failure (ARF; p < 0.001), and transfusion rates (p < 0.001). The OT patients also had significantly greater dislocation rates (p = 0.010), wound dehiscence (p = 0.03) and deep surgical-site infections (SSI; p = 0.002). The mean length of hospital stay (3.55 ± 4.89 days in OT vs 2.32 ± 2.52 days in NOT; p < 0.001), cost of care ($82,567.89 ± 74,505.54 vs $66,845.18 ± 47,761.39 for OT and NOT groups, respectively; p < 0.001) and mortality (p = 0.04) were significantly greater in the OT population, as compared to controls.

Conclusion

Organ transplant patients have significantly greater risk for developing post-operative complications like anemia, ARF, need for higher transfusion rates, prosthetic dislocations, wound dehiscence, and deep SSI following THA. The length of stay, total expenditure incurred and mortality were also higher in OT patients undergoing THA.

Assessing the hospital volume-outcome relationship in total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty (TEA) is an effective intervention for multiple elbow disorders including complex fracture in elderly patients, post-traumatic arthropathy, inflammatory arthropathy, and distal humeral nonunion. Given its known therapeutic value and low utilization rate, an investigation into the thresholds for TEA institutional volume-outcome relationships is warranted. The purpose of this study was to identify TEA volume thresholds that serve as predictors of institutional outcomes including complications, readmissions, revisions, cost of care, length of stay (LOS), and non-home discharge. We hypothesized that increased institutional volume would be associated with decreased 90-day adverse outcomes and resource utilization.

METHODS

The Nationwide Readmission Database was queried from 2010 to 2017 to identify all cases of TEA. Hospital volume was calculated using a unique hospital identifier and divided into quartiles. Outcomes such as complications, readmissions, revisions, cost of care, LOS, and non-home discharge were then analyzed by quartile. The same outcomes were assessed via stratum-specific likelihood ratio (SSLR) analysis to define volume strata among institutions.

RESULTS

SSLR analysis defined statistically significant hospital volume categories for each 90-day outcome. The volume category with the lowest complication rate was ≥21 TEAs per year (5.6%). The volume categories with the lowest readmission rates were 1-3 TEAs per year (4.7%) and ≥18 TEAs per year (9.2%). Revision rates were lowest in the volume categories of 1-5 TEAs per year (0.1%) and ≥18 TEAs per year (0.1%). Hospitals with ≥21 TEAs per year had the lowest cost of care and the highest rate of extended LOS (>2 days). SSLR analysis showed that non-home discharges decreased in a stepwise manner as volume increased. The lowest non-home discharge rate was associated with the volume category of ≥22 TEAs per year (20.3%).

CONCLUSION

This study defines TEA volume strata for institutional outcomes. The highest TEA volume strata were associated with the lowest rates of 90-day complications, revisions, and non-home discharges and the lowest cost of care. This trend is likely attributable to the benefits of high-volume institutional experience and standardized patient-care processes.

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair

BACKGROUND

Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients.

METHODS

The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis.

RESULTS

Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1).

CONCLUSION

Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.

A retrospective matched cohort single-center study evaluating outcomes of COVID-19 and the impact of immunomodulation on COVID-19-related cytokine release syndrome in solid organ transplant recipients

This retrospective matched cohort study describes 30 solid organ transplant (SOT) patients with Coronavirus Disease 2019 (COVID-19) matched 1:2 to 60 non-SOT patients (control group) based on age, body mass index (BMI), and comorbidities (hypertension and diabetes mellitus with hemoglobin A1c > 8.0%). The SOT group had a higher proportion of cardiovascular disease (P < .05). During the index hospitalization, there were no significant differences with regard to disease severity or critical care needs (mechanical intubation, vasopressors, and renal replacement therapy). At 28 days, 4 (13%) patients died in the SOT group and 8 (13%) patients died in the control group (P = 1.0). Nineteen patients received tocilizumab in the SOT group compared to 29 patients in the control group. Among these patients, interleukin-6 (IL-6) and soluble interleukin-2 receptor (sIL2R) levels increased after tocilizumab and interleukin-10 (IL-10) levels decreased after tocilizumab. Overall, SOT patients had comparable mortality to non-SOT patients, although numerically more SOT patients received tocilizumab (63% vs 48%) and steroids (37% vs 20%). Larger, multi-center studies are needed to ascertain these findings. Lastly, the complex cytokine release syndrome in COVID-19 remains an area of intense research and the analysis of key interleukin levels (IL-6, IL-10, and sIL2R) in this study contributes to the understanding of this process.

Shoulder arthroplasty in solid organ transplant patients: a retrospective, match paired analysis

BACKGROUND

Several studies have evaluated total hip and knee arthroplasty in solid organ transplant (SOT) patients; however, there are limited studies evaluating shoulder arthroplasty in SOT patients. This study compares the complications and functional outcomes of SOT patients undergoing shoulder arthroplasty with a matched control group.

METHODS

The institution's database was retrospectively reviewed for patients with a history of SOT undergoing primary shoulder arthroplasty (with minimum 2-year follow-up) and compared with a control group matched for age, sex, preoperative diagnosis, and surgical procedure. Preoperative and postoperative range of motion and outcome scores, perioperative surgical and medical complications, hospital length of stay, and mortality were compared.

RESULTS

Fifteen patients with previous SOT underwent 19 shoulder arthroplasties. Thirty-four underwent 35 shoulder arthroplasties in the control group. At last follow-up, the SOT group had a significantly worse UCLA score. The SOT group had a significantly worse improvement in UCLA, active elevation, and passive elevation scores in pre- to postoperative scores. There was no difference in length of stay, infection, or surgical complications. Ninety-day readmissions, medically related complications, and required blood transfusion were significantly higher in the SOT group. There was increased mortality in the SOT compared with the control group (death occurred on average 1577 days after arthroplasty).

CONCLUSION

Shoulder arthroplasty in patients with previous SOT appears safe and effective for degenerative shoulder disorders. Patients should be counseled preoperatively that their range of motion and function may not improve as much as their nontransplant cohorts. SOT patients may have increased incidence of postoperative blood transfusions and medically related complications.