Trends in total knee and hip arthroplasty recipients: a retrospective cohort study

Optimal inputs for machine learning models in predicting total joint arthroplasty outcomes: a systematic review

INTRODUCTION

Machine learning (ML) models may offer a novel solution to reducing postoperative complication rates and improving post-surgical outcomes after total joint arthroplasty (TJA). However, the variety of different ML models that exist paired with the increasing number of potential inputs can make the implementation of this tool challenging. Therefore, we conducted a systematic review to assess the most optimal inputs of different ML models in predicting postoperative (1) medical outcomes, (2) orthopedic outcomes, and (3) patient-reported outcome measures (PROMs) after total joint arthroplasty.

METHODS

The PubMed, MEDLINE, EBSCOhost, and Google Scholar databases were utilized to identify all studies evaluating ML models predicting outcomes following TJA between January 1, 2000, and June 23, 2023 (PROSPERO study protocol registration: CRD42023437586). The mean risk of bias in non-randomized studies-of interventions score, was 13.8 ± 0.5. Our initial query yielded 656 articles, of which 25 articles aligned with our aims, examining over 20 machine learning models and 1,555,300 surgeries. The area under the curve (AUC), accuracy, inputs, and the importance of each input were reported.

RESULTS

Twelve studies evaluating medical complications with 13 ML models reported AUCs ranging from 0.57 to 0.997 and accuracy between 88% and 99.98%. Key predictors included age, hyper-coagulopathy, total number of diagnoses, admission month, and malnutrition. Five studies evaluating orthopedic complications with 10 ML models reported AUCs from 0.49 to 0.93 and accuracy ranging from 92 to 97%, with age, BMI, CCI, AKSS scores, and height identified as key predictors. Ten studies evaluating PROMs comprising of 12 different ML models had an AUC ranging from 0.453 to 0.97 ranked preoperative PROMs as the post-predictive input. Overall, age was the most predictive risk factor for complications post-total joint arthroplasty (TJA).

CONCLUSION

These studies demonstrate the predictive capabilities of these models for anticipating complications and outcomes. Furthermore, these studies also highlight ML models' ability to identify non-classical variables not commonly considered in addition to confirming variables known to be crucial. To advance the field, forthcoming research should adhere to established guidelines for model development and training, employ industry-standard input parameters, and subject their models to external validity assessments.

Comparative effectiveness of neuraxial versus general anesthesia in total joint replacement surgery: an updated retrospective analysis using more recent data

INTRODUCTION

Over a decade ago, our study group showed improved outcomes among total hip/knee arthroplasty (THA/TKA) patients given neuraxial versus general anesthesia. As the use of neuraxial anesthesia has increased and anesthesia practices evolve, updated analyses are critical to ensure if previously found differences still persist.

METHODS

This retrospective cohort study included elective THA/TKAs from 2006 to 2021 as recorded in the all-payor Premier Healthcare Database. Multivariable regression models measured the association between anesthesia type (neuraxial, general, combined) and several adverse outcomes (pulmonary embolism, cerebrovascular events, pulmonary compromise, cardiac complications, acute myocardial infarction, pneumonia, all infections, acute renal failure, gastrointestinal complications, postoperative mechanical ventilation, intensive care unit admissions, and blood transfusions); models were run separately by period (2006-2015 and 2016-2021) and THA/TKA.

RESULTS

We identified 587,919 and 499,484 THAs for 2006-2015 and 2016-2021, respectively; this was 1,186,483 and 803,324 for TKAs. Among THAs, neuraxial anesthesia use increased from 10.7% in 2006 to 25.7% in 2021; during both time periods, specifically neuraxial versus general anesthesia was associated with lower odds for most adverse outcomes, with sometimes stronger (protective) effect estimates observed for 2016-2021 versus 2006-2015 (eg, acute renal failure OR 0.72 CI 0.65 to 0.80 vs OR 0.56 CI 0.50 to 0.63 and blood transfusion OR 0.91 CI 0.89 to 0.94 vs OR 0.44 CI 0.41 to 0.47, respectively; all p<0.001). Similar patterns existed for TKAs.

CONCLUSION

These findings re-confirm our study group's decade-old study using more recent data and offer additional evidence toward the sustained benefit of neuraxial anesthesia in major orthopedic surgery.

[Translated article] Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis

INTRODUCTION

The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA).

MATERIALS AND METHODS

Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed.

RESULTS

248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05).

CONCLUSIONS

No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis

INTRODUCTION

The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA).

MATERIALS AND METHODS

Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed.

RESULTS

248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05).

CONCLUSIONS

No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population-based study

INTRODUCTION

A large body of literature suggests that peripheral nerve blockade (PNB) is associated with improved perioperative outcomes in total hip and knee joint arthroplasty patients. However, it is unclear to what extent this association exists across patient subgroups based on age and health status.

METHODS

Patients who underwent total joint arthroplasty were identified from the Premier Healthcare database (2006-2019). Mixed-effects models were applied to assess the relationship between exposure of interest (PNB use on the day of surgery) and various outcomes (postoperative respiratory complications, acute renal failure, delirium, intensive care unit admission, prolonged length of stay, and high opioid consumption) across multiple subgroups stratified by patient age and pre-existing comorbidities.

RESULTS

PNB use and outcome association varies based on the patient's health and age characteristics. For adults and older adults with excellent or fair, there was a decrease in the likelihood of respiratory complication with the use of PNB (OR: 0.92, 95% CI 0.86 to 0.98; OR: 0.88, 95% CI 0.81 to 0.95; OR: 0.94, 95% CI 0.89 to 0.99, respectively). Peripheral nerve blocks were also associated with a reduction in the odds of high opioid consumption across all categories except adult patients in poor health.

CONCLUSION

PNB use is associated with beneficial effects more commonly observed among patients with a lower comorbidity burden, without a clear pattern of association with patient age.

Efficacy and safety of continuous nursing in improving functional recovery after total hip or knee arthroplasty in older adults: A systematic review

Objective

This systematic review was conducted to evaluate the efficacy and safety of continuous nursing care for the recovery of joint function in older adults with total hip or knee arthroplasty.

Methods

Randomized controlled trials and cohort studies of continuous nursing in older patients after joint replacement were searched from the database of Cochrane Library, Web of Science, PubMed, and Embase from their establishment to October 25, 2023. After literature screening, two researchers completed data extraction, and the risk of bias was assessed using the Cochrane risk-of-bias tool. The risk analysis included in cohort studies was based on the Newcastle-Ottawa Scale (NOS).

Results

The study included a total of 15 articles, comprising 34,186 knee and hip replacement patients. In this review, the effects of continuous nursing on the recovery of joint function of knee replacement and hip replacement in older adults were classified and discussed. Continuous nursing interventions targeted for total hip replacement could greatly increase the range of joint mobility, enhance muscle strength during hip movements like flexion, extension, and abduction, maintain joint stability, relieve pain, improve daily activities, and lower the risk of complications. For older patients with knee arthroplasty, continuous nursing programs could markedly improve knee motion range, joint flexion, joint stability, daily activities, and pain management. Despite the implementation of interventions, the incidence of complications caused by total knee replacement did not decrease. Out of all the studies reviewed, only one used a theoretical framework for interventions provided to patients during the postoperative period of hip arthroplasty. The overall quality of the included studies was very high.

Conclusion

Continuous nursing can effectively improve the joint function of older patients after joint replacement. However, its effectiveness in terms of clinical outcomes, patient satisfaction, and medical cost of associated continuous nursing needs to be further clarified. In addition, continuous nursing has no significant advantage in the safety of postoperative complications and readmission rates in older adults after knee joint replacement. To enhance the efficacy and safety of continuous nursing effectively, it is crucial to refine the continuous nursing program in the future, thereby elevating the quality of nursing services.

Observed Differences in Patient Comorbidities and Complications Undergoing Primary Total Joint Arthroplasty Between Non-orthopaedic and Orthopaedic Referral Patients

BACKGROUND

Value-based total joint arthroplasty (TJA) has resulted in decreasing surgeon reimbursement which has created concern that surgeons are being incentivized to avoid medically complex patients. The purpose of this study was to determine if patients who underwent primary total knee (TKA) and total hip arthroplasty (THA) had different comorbidities and complication rates based on referral type: 1) non-orthopaedic referral (NOR), 2) outside orthopaedic referral (OOR) or 3) self-referral (SR).

METHODS

At a single tertiary care centre, patients undergoing primary TJA between July 2019 and January 2020 were identified using current procedural codes. Data were abstracted from the Institutional National Surgical Quality Improvement Program (NSQIP) along with electronic medical records which included referral type, primary insurance, demographics, comorbidities, and comorbidity scores, including an American Society of Anesthesiology (ASA) score. Complications and outcomes were tracked for 90 days post-operatively. Referral groups were compared using Chi-square exact tests for categorical variables and t-tests or Wilcoxon Rank Sum tests for continuous variables, as appropriate.

RESULTS

Of the 393 patients included in this study, there were 249 (63%) NOR, 104 (26%) OOR, and 40 (10%) SR. The OOR versus NOR group had a significantly greater proportion of patients with obesity (79 vs 64%, p=0.047) and an ASA score ≥3 (59 vs 43%, p=0.007). There was a significantly greater proportion of patients with wound complications (10 vs 4%, p=0.023) and ≥2 complications (14 vs 3%, p<0.001) in OOR versus NOR, respectively.

CONCLUSION

Patients who underwent primary TJA and were referred by an orthopaedic surgeon tended to have more comorbid conditions and higher rates of severe complications. The observed difference in referrals may be explained by monetary incentivization in the context of current reimbursement trends. Organizations utilizing bundled payment programs to reimburse surgeons should use a risk-stratification model to mitigate incentivizing surgeons to avoid medically complex patients.

Effect of preoperative warming on intraoperative hypothermia and postoperative functional recovery in total hip arthroplasty: a randomized clinical trial

BACKGROUND

Intraoperative hypothermia is associated with increased morbidity and impaired postoperative recovery. Direct anterior-approached total hip arthroplasty (ATHA) may lead to significant thermal loss. We aimed to assess whether preoperative warming had an impact on intraoperative hypothermia and postoperative functional recovery after ATHA.

METHODS

In this prospective randomized controlled clinical trial 40 patients scheduled for ATHA were randomly divided into two groups of 20 patients each. Group W received, prior to the induction of general anesthesia, a 30 minutes 43 °C forced-air preoperative warming. Group C did not receive any preoperative warming. A blinded observer noted the core body temperature at the time of induction and at fixed time points, i.e. every five minutes during the first hour of surgery. The evolution of postoperative patient perceived thermal comfort (TC) and functional recovery (QoR-15) was assessed 24, 48 and 72 hours after surgery. Length of stay in the post-anesthesia care unit (PACU) was noted.

RESULTS

The temperature drop was significantly faster and of higher amplitude in group C than in group W, during first hour of surgery (P<0.001). Evolution of QoR-15 and TC was significantly better in group W than in group C (P<0.001 for QoR-15 and P<0.001 for thermal comfort), with shorter length of stay (median [IQR]) in the PACU (minutes; 73 [61-79] for group C and 98 [83-129] for group W, P<0.001).

CONCLUSIONS

In ATHA, pre-warming delays and reduces intraoperative heat loss, impacting patient comfort and postoperative functional recovery.

Association of patient characteristics with the receipt of regional anesthesia

BACKGROUND

Regional anesthesia (RA) may improve patient-related outcomes, including decreased operative complications, shortened recovery times, and lower hospital readmission rates. More analyses are needed using a diverse set of databases to examine characteristics associated with the receipt of RA.

METHODS

A national hospital database was queried for patients 18 years or older who underwent total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, ankle open reduction, and internal fixation and arteriovenous fistula creation between January 2016 and June 2021. Regional techniques included neuraxial anesthesia and various upper and lower extremity peripheral nerve blocks to create a binary variable of RA receipt. Univariate statistics were used to compare characteristics associated based on RA receipt and multivariable regression identified factors associated with RA receipt.

RESULTS

A total of 51 776 patients were included in the analysis, of which 2111 (4.1%) received RA. Factors associated with decreased odds of RA receipt included black race (vs white race; OR 0.73, 95% CI 0.62 to 0.86), other non-white race (vs white race; OR 0.71, 95% CI 0.61 to 0.86), American Society of Anesthesiologists (ASA) class (vs ASA 1; OR 0.85, 95% CI 0.79 to 0.93), and Medicaid insurance (vs private insurance; OR 0.65, 95% CI 0.51 to 0.82) (all p<0.05). When compared with TKA, ACLR (OR 0.67, 95% CI 0.53 to 0.84), ankle open reduction and internal fixation (OR 0.68, 95% CI 0.58 to 0.81), and carpal tunnel release (OR 0.68, 95% CI 0.59 to 0.78) demonstrated lower odds of RA receipt, whereas TSA (OR 1.31, 95% CI 1.08 to 1.58) demonstrated higher odds of RA receipt (all p<0.05).

CONCLUSION

RA use varies with respect to race, insurance status, and type of surgery.

Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study

PURPOSE

International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique.

METHODS

We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia.

RESULTS

The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%.

CONCLUSION

Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.

Effect of knee joint weight change on knee function recovery and gait after total knee arthroplasty

Background

Knee osteoarthritis (KOA) is a common disease based on degenerative pathological changes. Total knee arthroplasty (TKA) is an effective treatment for end-stage of KOA. However, only volume adaptation can be achieved with current knee prostheses, and it is difficult to achieve weight adaptation. This study focused on the weight difference of knee joints and initially explored the impact of this change on knee joint functional recovery and gait changes in patients after surgery.

Methods

From October 2015 to June 2019, patients who underwent primary unilateral TKA were enrolled in this prospective cohort study with the same brand of knee prostheses. General data were collected from patients who met the criteria. The resected bone and soft tissues were collected and weighed precisely during TKA, and multivariate regression analysis was used to determine the factors affecting the weight of the removed knee tissues. We compared the weight of excised tissues and the total weight of the knee prosthesis, and the weight difference was defined as the increased weight of the knee joint (IWKJ). All patients were evaluated by HSS score, gait analysis, and affected side knee X-ray at two weeks, three months, and the last follow-up after the operation. To further determine the influence of IWKJ on postoperative functional recovery, the relationship between IWKJ, HSS score, and gait analysis was analyzed by univariate regression.

Results

In total, 210 patients were eventually included in observation. All patients underwent postoperative follow-up for no less than two years. Multiple regression analysis showed that the course of the disease, body weight, and kellgren-Larencen stage(K-L stage)of the affected knee joint were independent factors affecting the weight of the removed knee tissues and were positively correlated with it. Univariate analysis showed that IWKJ was negatively correlated with HSS score at two weeks and three months after the operation. In addition, the values of spatiotemporal parameters and knee rotation ROM were negatively correlated with IWKJ two weeks after surgery, while outside food load response was positively correlated with IWKJ. Cadence, knee rotation ROM, and Ankle rotation ROM were negatively correlated with IWKJ, while outside food was positively correlated with IWKJ three months after surgery. At the last follow-up, only the hip rotation ROM was positively correlated with IWKJ.

Conclusions

All Patients underwent TKA had varying degrees of increased knee weight. The increased weight was 298.98 ± 63.77 g. Patients' body weight, K-L staging, and disease duration are important factors that cause differences in resected knee tissue. Three months after the operation, the changes in knee joint weight had a negative correlation with the HSS score, which at the same time, it had varying degrees of linearity with gait parameters. However, the influence of weight diminished over time.

The Use of Critical Care Services After Orthopedic Surgery at a High-Volume Orthopedic Medical Center: A Retrospective Study

Background: With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. Purpose: We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. Methods: We retrospectively reviewed inpatient electronic medical record data (2016-2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Results: Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). Conclusions: This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery.

Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century?

BACKGROUND

Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening.

STUDY METHODS

We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed.

RESULTS

The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients.

DISCUSSION

Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.

Comparison of General and Spinal Anaesthesia on Systemic Inflammatory Response in Patients Undergoing Total Knee Arthroplasty: A Propensity Score Matching Analysis

Background and Objectives: Some of the postoperative complications following orthopaedic surgeries are associated with a systemic inflammatory response (SIR), which varies depending on the anaesthetic technique. We aimed to compare the effects of general and spinal anaesthesia on the SIR after total knee arthroplasty (TKA), based on C-reactive protein (CRP) levels, the platelet-lymphocyte ratio (PLR), and the neutrophil-lymphocyte ratio (NLR). Materials and Methods: Patients who underwent TKA between January 2014 and December 2018 were included. Electronic medical records of the patients were retrospectively reviewed and analysed. To reduce the impact of potential confounding factors, we performed propensity score matching according to the anaesthetic technique. Results: A total of 1311 TKA cases were analysed. After propensity score matching, the maximal CRP value and changes in CRP levels in the general anaesthesia group were higher than those in the spinal anaesthesia group. However, the maximal NLR and PLR and the changes in NLR and PLR were not different between the two groups. There were no differences in postoperative clinical outcomes. Conclusion: Spinal anaesthesia tended to induce a lower inflammatory response than general anaesthesia when considering CRP levels in patients undergoing TKA. However, the effects of anaesthetic techniques on the overall outcomes were not significant.

Interprosthetic Femoral Fractures Surgical Treatment in Geriatric Patients

Background

Total hip (THA) and total knee arthroplasty (TKA) are becoming an increasingly standard procedure in the whole world. In conjunction with an aging population and increased prevalence of osteoporosis, proper management of periprosthetic, and interprosthetic fractures is of great interest to orthopedic surgeons. This study aims to report the clinical and radiographic outcomes, complications and reoperations of IFFs in geriatric patients.

Methods

A retrospective single-institution case series study was conducted. Between 2011 and 2019, 83 patients underwent surgical treatment for periprosthetic femoral fractures. Thirteen fractures were identified as IFFs. Patient demographics and comorbidities were collected preoperatively, and fractures were classified with the Vancouver and AO unified classification system (AO-UCS).

Results

We included 12 patients (13 hips) with IFFs (AO-UCS type IV.3 B (2/13) type IV.3 C (3/13), type IV.3 D (8/13)). The average patient age was 86.54 (range, 79-89) years. There were 10 females and 2 males. Perioperative morbidity has been identified in 10 of the 12 patients, and the 3-month and 1-year mortality were reported in 2 and 3 patients, respectively. Cerclage cables were used in 9 of 12 patients. One of 12 patients showed a local complication, with no documented implant failure or revision. Patients achieved complete union and returned to their preoperative ambulatory status, and full weight-bearing at an average of 5 (range, 2 to 7) months later.

Conclusion

Management of IFF can be challenging because these fractures require extensive surgical expertise. Locking plate seems to be a valuable treatment option for geriatric patients with IFFs. Despite the complexity of this type of fracture, the overall complication and revision rate, as well as the radiographic outcome are good to excellent.

Level of Evidence

Level III, Therapeutic study.

Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study

BACKGROUND

Scarce data exist on differential opioid prescribing between men and women in the pre-, peri-, and postoperative phases of care among patients undergoing total hip/knee arthroplasty (THA/TKA).

METHODS

In this retrospective population-based study, Truven Health MarketScan claims data were used to establish differences between men and women in (1) opioid prescribing in the year before THA/TKA surgery, (2) the amount of opioids prescribed at discharge, and (3) chronic opioid prescribing (3-12 months after surgery). Multivariable regression models measured odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

Among 29 038 THAs (42% men) and 48 523 TKAs (52% men) men (compared with women) were less likely to receive an opioid prescription in the year before surgery (54% vs 60%, and 54% vs 60% for THA and TKA, respectively); P<0.001. However, in multivariable analyses male sex was associated with higher total opioid dosages prescribed at discharge after THA (OR=1.04; 95% CI 1.03, 1.06) and TKA (OR=1.05; 95% CI 1.04, 1.06); both P<0.001. Chronic opioid prescribing was found in 10% of the cohort (THA: n=2333; TKA: n=5365). Here, men demonstrated lower odds of persistent opioid prescribing specifically after THA (OR=0.90; 95% CI 0.82, 0.99) but not TKA (OR=0.96; 95% CI 0.90, 1.02); P=0.026 and P=0.207, respectively.

CONCLUSIONS

We found sex-based differences in opioid prescribing across all phases of care for THA/TKA. The results highlight temporal opportunities for targeted interventions to improve outcomes after total joint arthroplasty, particularly for women, and to decrease chronic opioid prescribing.

The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas

Background

Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA.

Methods

Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year.

Results

Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA.

Conclusion

Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.

Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017

“Fast-track” protocols has improved surgical care with a reduction in length of hospital stay (LOS) in total hip (THA) and knee arthroplasty (TKA). However, the effects of continuous refinement of perioperative care lack detailed assessment. We studied time-related changes in LOS and morbidity after THA and TKA within a collaboration with continuous scientific refinement of perioperative care. Prospective multicentre consecutive cohort study between 2010 and 2017 from nine high-volume orthopaedic centres with established fast-track THA and TKA protocols. Prospective collection of comorbidities and complete 90-day follow-up from the Danish National Patient Registry and medical records. Of 36,935 procedures median age was 69 [62 to 75] years and 58% women. LOS declined from three [two to three] days in 2010 to one [one to two] day in 2017. LOS > 4 days due to “medical” or “surgical” complications, and “with no recorded morbidity” declined from 4.4 to 2.7%, 1.5 to 0.6%, and 3.8 to 1.3%, respectively. 90-days readmission rate declined from 8.6 to 7.7%. Our multicentre study in a socialized healthcare setting was associated with a continuous reduction in LOS and morbidity after THA and TKA.

Is obesity associated with short-term revision after total knee arthroplasty? An analysis of 121,819 primary procedures from the Dutch Arthroplasty Register

BACKGROUND

The prevalence of obesity is increasing. The association with knee osteoarthritis is well documented, resulting in the population requesting total knee arthroplasty (TKA) for invalidating symptoms to be heavier in nature. The purpose of the current analysis was to assess the association between preoperative body mass index (BMI) and short-term revision rate after TKA. The secondary aim was to investigate the influence of implant fixation method on the association between BMI and survivorship.

METHODS

This is a retrospective analysis of prospectively collected registry data (Dutch Arthroplasty Register; LROI). All primary TKA procedures in patients >18 years of age with registered BMI were selected (n = 121,819). Non-obese patients (BMI 18-25) were compared with overweight (BMI 25-30) and class I-III obese (BMI >30, >35, >40) patients. Crude all-cause revision rates were calculated using competing risk analysis. Adjusted hazard ratios (HRs) were determined with Cox multivariable regression analyses for all-cause, septic and aseptic revision and secondary patellar resurfacing.

RESULTS

Revision rates were 3.3% for non-obese patients, 3.5% for overweight patients, 3.7% for class I obese patients, 3.6% for class II obese patients and 3.7% for class III obese patients. Class III obese patients had a significant higher risk for septic revision compared with non-obese patients (HR 1.53, 95% confidence interval (CI) 1.06-2.22). Class I obese patients had a higher risk for secondary patellar resurfacing (HR 1.52, 95% CI 1.12-2.08). All-cause and aseptic revision rates were similar between BMI groups.

CONCLUSIONS

Obesity appeared to be associated with some short-term revision risks after TKA, but was not associated with an overall increase in revision rate.

Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty

Background

Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB).

Methods

We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.

Results

The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both TKA and THA patient groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions between patients who underwent spinal and general anesthesia in both TKA and THA groups.

Conclusions

A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.