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Chandrupatla S, Rumalla K, Singh JA. Association between diabetes mellitus and total hip arthroplasty outcomes: an observational study using the US National Inpatient Sample. BMJ Open 2024; 14:e085400. [PMID: 39038867 DOI: 10.1136/bmjopen-2024-085400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVES To investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA). DESIGN Retrospective cohort study using data from the US National Inpatient Sample (NIS). SETTING Study cohort was hospitalisations for primary THA in the USA, identified from the 2016-2020 NIS. PARTICIPANTS We identified 2 467 215 adults in the 2016-2020 NIS who underwent primary THA using International Classification of Diseases, 10th Revision codes. Primary THA hospitlizations were analysed as the overall group and also stratified by the underlying primary diagnosis for THA. OUTCOME MEASURES Outcome measures of interest were the length of hospital stay>the median, total hospital charges>the median, inpatient mortality, non-routine discharge, need for blood transfusion, prosthetic fracture, prosthetic dislocation and postprocedural infection, including periprosthetic joint infection, deep surgical site infection and postprocedural sepsis. RESULTS Among 2 467 215 patients who underwent primary THA, the mean age was 68.7 years, 58.3% were female, 85.7% were white, 61.7% had Medicare payer and 20.4% had a Deyo-Charlson index (adjusted to exclude diabetes mellitus) of 2 or higher. 416 850 (17%) patients had diabetes. In multivariable-adjusted logistic regression in the overall cohort, diabetes was associated with higher odds of a longer hospital stay (adjusted OR (aOR) 1.38; 95% CI 1.35 to 1.41), higher total charges (aOR 1.11; 95% CI 1.09 to 1.13), non-routine discharge (aOR 1.18; 95% CI 1.15 to 1.20), the need for blood transfusion (aOR 1.19; 95% CI 1.15 to 1.23), postprocedural infection (aOR 1.62; 95% CI 1.10 to 2.40) and periprosthetic joint infection (aOR 1.91; 95% CI 1.12 to 3.24). We noted a lack of some associations in the avascular necrosis and inflammatory arthritis cohorts (p>0.05). CONCLUSION Diabetes was associated with increased healthcare utilisation, blood transfusion and postprocedural infection risk following primary THA. Optimisation of diabetes with preoperative medical management and/or institution of specific postoperative pathways may improve these outcomes. Larger studies are needed in avascular necrosis and inflammatory arthritis cohorts undergoing primary THA.
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Affiliation(s)
- Sumanth Chandrupatla
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kranti Rumalla
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jasvinder A Singh
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Medicine Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
- Medicine Service, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Zhang Z, Driskill E, Chi J, Duensing I, Cui Q. Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Marfan Syndrome. J Arthroplasty 2024; 39:1726-1730. [PMID: 38211728 DOI: 10.1016/j.arth.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 12/16/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Outcomes of Marfan syndrome (MFS) patients after total knee arthroplasty (TKA) are poorly documented in the literature. The purpose of this study was to evaluate MFS as a potential risk factor for complications after TKA. METHODS Using a national private payer insurance database from 2010 to 2022, MFS patients undergoing primary TKA were identified and compared to 10:1 matched controls based on age, sex, obesity, diabetes mellitus, and a comorbidity index. A total of 4,092 patients undergoing primary TKA were analyzed, of which 372 had MFS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department-visits and inpatient readmissions were also documented. RESULTS Compared to the matched controls, patients who have MFS displayed elevated rates of surgical complications, including prosthetic instability (1-year, odds ratio (OR) 3.88, 95% confidence interval (CI) [1.58 to 8.66]; 2-year, OR 4.39, 95% CI [2.16 to 8.44]), and revision surgery (2 year, OR 1.79, 95% CI [1.05 to 2.91]). Additionally, patients who have MFS demonstrated significant higher rates of medical complications, including aortic dissection (2.15 versus 0%) and transfusion (OR 2.63, 95% CI [1.31 to 4.90]). CONCLUSIONS Patients who have MFS are at higher risks of postoperative complications after TKA, encompassing both medical and surgical complications. Specifically, patients who have MFS have a significantly higher likelihood of experiencing prosthetic instability and requiring revision surgery. Given these results, it is crucial for orthopedic surgeons and patients alike to consider these risks when determining a course of TKA for patients who have MFS.
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Affiliation(s)
- Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; Department of Orthopaedic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, China
| | - Elizabeth Driskill
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ian Duensing
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
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Sleiman AG, Vallette N, Milto AJ, Revelt N, Scaife SL, Thuppal SV. The effect of autoimmune skin disorders on post-operative outcomes following arthroplasty. Surgeon 2023; 21:e292-e300. [PMID: 37028955 DOI: 10.1016/j.surge.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/17/2023] [Accepted: 03/20/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION The impact of autoimmune skin disorders on post-operative outcomes after TJA is conflicting and studies are limited by small sample sizes. The purpose of this study is to analyze a range of common autoimmune skin disorders and identify whether an increased risk of post-operative complication exists after total joint arthroplasty. METHODS Data was collected from NIS database for patients diagnosed with autoimmune skin disorder (psoriasis, lupus, scleroderma, atopic dermatitis) and who underwent total hip arthroplasty (THA), total knee arthroplasty (TKA), or other TJA (shoulder elbow, wrist, ankle) between 2016 and 2019. Demographic, social, and comorbidity data was collected. Multivariate regression analyses were performed to assess the independent influence of autoimmune skin disorder on each post-operative outcome including implant infection, transfusion, revision, length of stay, cost, and mortality. RESULTS Among 55,755 patients with autoimmune skin disease who underwent TJA, psoriasis was associated with increased risk of periprosthetic joint infection following THA (odds ratio 2.44 [1.89-3.15]) and increased risk of transfusion following TKA (odds ratio 1.33 [1.076-1.64]). Similar analyses were performed for systemic lupus erythematosus, atopic dermatitis, and scleroderma, however no statistically significant associations were observed in any of the six collected post-operative outcomes. CONCLUSION This study suggests psoriasis is an independent risk factor for poorer post-operative outcomes following total joint arthroplasty, however similar risk was not observed for other autoimmune skin disorders such as lupus, atopic dermatitis, or scleroderma.
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Affiliation(s)
- Anthony G Sleiman
- Division of Orthopedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL P.O. Box 19679, Springfield, IL, 62794, USA; Center for Clinical Research, Southern Illinois University School of Medicine, 201 E. Madison St., Springfield, IL, 62702, USA
| | - Noah Vallette
- Division of Orthopedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL P.O. Box 19679, Springfield, IL, 62794, USA
| | - Anthony J Milto
- Division of Orthopedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL P.O. Box 19679, Springfield, IL, 62794, USA
| | - Nicolas Revelt
- Division of Orthopedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL P.O. Box 19679, Springfield, IL, 62794, USA
| | - Steven L Scaife
- Center for Clinical Research, Southern Illinois University School of Medicine, 201 E. Madison St., Springfield, IL, 62702, USA
| | - Sowmyanarayanan V Thuppal
- Division of Orthopedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL P.O. Box 19679, Springfield, IL, 62794, USA; Center for Clinical Research, Southern Illinois University School of Medicine, 201 E. Madison St., Springfield, IL, 62702, USA.
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Viswanathan VK, Sakthivelnathan V, Menedal A, Purudappa PP, Mounasamy V, Sambandam S. How does systemic lupus erythematosus impact the peri-operative complication rates in primary hip arthroplasty? A national inpatient sample-based study. Arch Orthop Trauma Surg 2023; 143:2209-2216. [PMID: 35643817 DOI: 10.1007/s00402-022-04475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/05/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION With prolonged life expectancy, the number of patients with systemic lupus erythematosus (SLE) undergoing total hip arthroplasty (THA) has substantially increased over the past years. The post-operative outcome and complications in SLE are less clearly understood than other inflammatory diseases, due to limited availability of evidence within the literature. METHODS Using the National Inpatient Sample (NIS) database, patients who underwent THA between 2016 and 2019 were identified (ICD-10 CMP code). Patients were then classified into one of the two groups, namely those with SLE (ICD-10-CM; code710.0) or those without SLE (NSLE). Data regarding demographic details, co-morbidities, details regarding hospital stay, expenditure incurred, and complications encountered were analyzed, and compared between the groups. RESULTS Overall, among 367,894 patients undergoing THA, 1684 (0.5%) had SLE. Mean age of SLE (57.3 ± 14.5 years) patients undergoing THA was significantly lower than NSLE (65.9 ± 11.4 years) population (p = 0.001). There was a greater proportion of female patients in SLE group [89.6% (SLE) vs 55.8% (NSLE); p = 0.001]. SLE patients had a greater incidence of emergent hospital admissions (p = 0.04), longer hospital stay (p = 0.001), and higher hospital-related expenditure (p = 0.001). Among the peri-operative complications, SLE patients had significantly greater risk of developing post-operative anemia (p = 0.001), need for blood transfusion (p = 0.001), peri-prosthetic mechanical complications (p = 0.04), and prosthetic dislocations (p = 0.001). There was also a greater incidence of peri-prosthetic infections in the SLE group (p = 0.001). CONCLUSION The presence of SLE significantly lengthens hospital stay and augments healthcare-related costs in patients undergoing THA. The three main complications which may significantly affect the post-operative course of these patients include higher rates of post-operative anemia, peri-prosthetic infections, and early prosthetic dislocations.
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Affiliation(s)
| | | | | | | | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, USA
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Does systemic lupus erythematosus impact the peri-operative complication rates following primary total knee arthroplasty? A national inpatient sample-based large-scale study. Arch Orthop Trauma Surg 2022; 143:3291-3298. [PMID: 35976411 DOI: 10.1007/s00402-022-04581-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/08/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Consequent to improved life expectancies, there has been a substantial increase in the proportion of patients with systemic lupus erythematosus (SLE) undergoing total knee arthroplasty (TKA) over the past 2 decades. In comparison to the other inflammatory disorders, the complication rates and post-operative outcome in patients with SLE are less clearly understood, owing to the paucity of evidence in the literature. METHODS Patients who underwent TKA between 2016 and 2019 were identified (ICD-10CMP code) using the National Inpatient Sample (NIS) database and then classified into one of the two groups, namely those with SLE (ICD-10-CM; code710.0) and those without SLE (NSLE). Demographic details, co-morbidities, details regarding hospital stay, costs incurred, and complications encountered of this patient cohort were analysed and compared between the two groups. RESULTS Overall, among 5,58,361 patients undergoing TKA, 2,094 (0.38%) patients had SLE. The SLE group was significantly younger than NSLE population (62.2 ± 9.9 vs 66.7 ± 9.5 years; p < 0.001). The proportion of female and African-American patients was higher in the SLE group (p < 0.001). SLE patients had a significantly longer hospital stay (p < 0.001) and greater hospital-related expenditure (p < 0.001). Among the peri-operative complications, SLE patients had significantly greater risk of developing post-operative anemia (19.2% in SLE vs 15.3% in NSLE; p < 0.001), requiring blood transfusion (2.8% in SLE vs 1.5% in NSLE; p < 0.001), and acquiring peri-prosthetic joint infections (1.9% in SLE vs 1% in NSLE; p < 0.001). CONCLUSION The presence of SLE significantly lengthens hospital stay, and augments the health-care-related costs in patients undergoing TKA. The rates of peri-prosthetic infections, post-operative anemia, and need for blood transfusions are significantly greater in SLE patients.
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Li Z, Xiang S, Du Y, Zhang M, Bian Y, Feng B, Weng X. Preoperative Use of Aspirin in Total Knee Arthroplasty: Safe or Not? Orthop Surg 2022; 14:1673-1680. [PMID: 35761756 PMCID: PMC9363720 DOI: 10.1111/os.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare the blood loss, transfusion rates and complications between the aspirin and non-aspirin group in unilateral and bilateral total knee arthroplasties (TKAs) with a nested case-control design. METHODS The present study retrospectively selected TKA cases from the Joint Arthroplasty Database at the Peking Union Medical College Hospital from January 2014 to December 2019 following strict inclusion and exclusion criteria, and divided them into the aspirin and non-aspirin group based on the use of aspirin preoperatively. Bleeding was measured by blood loss, transfusion rate, drainage volume, hemoglobin (HGB) and hematocrit (HCT), while complications (cardiovascular events, venous thromboembolism events, cerebrovascular events and wound events) were compared between the groups. Student's unpaired t-test and Mann-Whitney U-test were used to compare the differences of continuous variables between the two groups while chi-square test and Fisher's exact test were applied in categorical variables. RESULTS A total of 560 patients with unilateral TKA and 285 patients with bilateral TKA were extracted. Among these, 280 patients used aspirin preoperatively. No other differences were found in demographic and surgical characteristics between the two groups except for the proportion of coronary artery diseases (P < 0.001). For primary outcomes, there was no significant higher blood loss and transfusion rate in the aspirin group, while the drainage of aspirin group was higher than the control group in bilateral TKAs (P = 0.043). The HGB and HCT of the aspirin group was significant lower in both unilateral and bilateral TKAs at POD5 (P < 0.05). For complications, there was a lower vascular related complication rate in aspirin group after unilateral TKAs (P = 0.040), but the wound event rate in aspirin group was higher than the control group (P = 0.049). CONCLUSIONS Preoperative use of aspirin could prevent vascular related events during the perioperative period of TKA. However, it might also increase the risk of bleeding and wound complications.
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Affiliation(s)
- Zeng Li
- Department of Orthopedics Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Du
- Clinical Research, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Mo Zhang
- Clinical Research, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yanyan Bian
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Bin Feng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xisheng Weng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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Zisa D, Goodman SM. Perioperative Management of Rheumatic Disease and Therapies. Rheum Dis Clin North Am 2022; 48:455-466. [PMID: 35400371 DOI: 10.1016/j.rdc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
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Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
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Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
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Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
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Singh JA, Mehta B, Mirza SZ, Figgie MP, Sculco P, Parks M, Goodman SM. When Has a Knee or Hip Replacement Failed? A Patient Perspective. J Rheumatol 2019; 48:447-453. [PMID: 31787606 DOI: 10.3899/jrheum.191024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To define the patient perspective of what constitutes a failure of total joint replacement (TJR) in a qualitative study. METHODS We used the nominal group technique (NGT) with participants who had undergone elective total hip replacements (THR) and/or total knee replacements (TKR) to answer the question, "When would you consider a knee or hip replacement to be a failure?" RESULTS We performed 8 nominal groups with 42 participants, all of whom had undergone THR and/or TKR between 2016 and 2018. Of these, 48% were male, 17% were Black, 79% had college education or above, and 76% had had osteoarthritis as the underlying diagnosis. The nominated responses/themes that were ranked the highest by the participants were as follows: (1) refractory index joint pain (80 votes); (2) occurrence of postoperative adverse events (54 votes); (3) unable to resume normal activities or go back to work (38 votes); (4) little or no improvement in quality of life (35 votes); (5) early revision surgery (35 votes); (6) death (7 votes); and (7) other, including nurse or physician negligence (2 votes) and expectation-outcome mismatch (1 vote). CONCLUSION Lack of relief of pain or restoration of function or quality of life, or the occurrence of surgical complications after TJR were defined as TJR failure by participants. Functional TJR failure seems as important or more important than surgical failure. This patient perspective emphasizing pain, function, satisfaction, adverse events, and revision as critical domain components of TJR failure independently validated their inclusion in the TJR core domain set for clinical trials in people undergoing knee or hip TJR.
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Affiliation(s)
- Jasvinder A Singh
- J.A. Singh, MBBS, MPH, Birmingham VA Medical Center, and Department of Medicine at the School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;
| | - Bella Mehta
- B. Mehta, MD, S.Z. Mirza, BS, S.M. Goodman, MD, Department of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Serene Z Mirza
- B. Mehta, MD, S.Z. Mirza, BS, S.M. Goodman, MD, Department of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Mark P Figgie
- M.P. Figgie, MD, P. Sculco, MD, M. Parks, MD, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Peter Sculco
- M.P. Figgie, MD, P. Sculco, MD, M. Parks, MD, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Michael Parks
- M.P. Figgie, MD, P. Sculco, MD, M. Parks, MD, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Susan M Goodman
- B. Mehta, MD, S.Z. Mirza, BS, S.M. Goodman, MD, Department of Rheumatology, Hospital for Special Surgery, New York, New York
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