Understanding the 30-day mortality burden after revision total hip arthroplasty

Neighborhood Socioeconomic Disadvantage is Associated With Increased Health Care Utilization After Septic and Aseptic Revision Total Hip Arthroplasty

BACKGROUND

A greater area deprivation index (ADI), a tool that gauges socioeconomic disadvantage at the neighborhood level, is associated with worse health care outcomes following primary total hip arthroplasty. However, its association with revision total hip arthroplasty (rTHA) is unknown. This study aimed to determine the association between ADI and rates of postoperative health care resource utilization following rTHA.

METHODS

A total of 996 patients who underwent rTHA between 2016 and 2022 were enrolled in a prospective study. The primary outcomes assessed were nonhome discharge disposition (DD), length of stay (LOS) ≥ three days, 90-day emergency department (ED) visits, and 90-day hospital readmissions. The ADI was calculated using the patient's home address at the time of surgery, with greater ADI indicating greater socioeconomic disadvantage. We evaluated the mediation effect of patient race on ADI and postoperative health care utilization using a multivariable logistic regression model.

RESULTS

A higher median ADI was revealed for patients who experienced nonhome discharge (P = 0.001), extended LOS (P < 0.001), and ED readmission within 90 days of surgery (P = 0.045). When comparing septic versus aseptic rTHA patients, there were significant differences in health care resource utilization but no difference in ADI between the two groups. For aseptic rTHA, ADI significantly mediated the effect of race on both nonhome DD and LOS ≥ 3 (41 and 46% mediation, respectively). In septic rTHA, ADI mediated 31.1% of the effect of race on nonhome DD, but showed minimal mediation effect on LOS. The mediation effect of ADI on ED admission and hospital readmission was minimal for both groups.

CONCLUSIONS

Higher ADI scores are associated with increased health care utilization after rTHA, including longer hospital stays and more nonhome discharges. The ADI significantly mediates the effect of race on these outcomes, particularly in aseptic rTHA cases, suggesting that neighborhood socioeconomic factors play a crucial role in previously observed racial disparities.

Re-revision and mortality rate following revision total hip arthroplasty for infection

Aims

This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

Methods

This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA.

Results

The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA.

Conclusion

The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the 'real world'. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection.

Genetic correlations and causal relationships between cardio-metabolic traits and sepsis

Cardio-metabolic traits have been reported to be associated with the development of sepsis. It is, however, unclear whether these co-morbidities reflect causal associations, shared genetic heritability, or are confounded by environmental factors. We performed three analyses to explore the relationships between cardio-metabolic traits and sepsis. Mendelian randomization (MR) study to evaluate the causal effects of multiple cardio-metabolic traits on sepsis. Global genetic correlation analysis to explore the correlations between cardio-metabolic traits and sepsis. Local genetic correlation (GC) analysis to explore shared genetic heritability between cardio-metabolic traits and sepsis. Some loci were further examined for related genes responsible for the causal relationships. Genetic associations were obtained from the UK Biobank data or published large-scale genome-wide association studies with sample sizes between 200,000 to 750,000. In MR, we found causality between BMI and sepsis (OR: 1.53 [1.4-1.67]; p < 0.001). Body mass index (BMI), which is confirmed by sensitivity analyses and multivariable MR adjusting for confounding factors. Global GC analysis showed a significant correlation between BMI and sepsis (rg = 0.55, p < 0.001). More cardio-metabolic traits were identified to be correlated to the sepsis onset such as CRP (rg = 0.37, p = 0.035), type 2 diabetes (rg = 0.33, p < 0.001), HDL (rg = - 0.41, p < 0.001), and coronary artery disease (rg = 0.43, p < 0.001). Local GC revealed some shared genetic loci responsible for the causality. The top locus 1126 was located at chromosome 7 and comprised genes HIBADH, JAZF1, and CREB5. The present study provides evidence for an independent causal effect of BMI on sepsis. Further detailed analysis of the shared genetic heritability between cardio-metabolic traits and sepsis provides the opportunity to improve the preventive strategies for sepsis.

30-day to 10-year mortality rates following total hip arthroplasty: a meta-analysis of the last decade (2011-2021)

BACKGROUND

Mortality after total hip arthroplasty (THA) is a rare but devastating complication. This meta-analysis aimed to: (1) determine the mortality rates at 30 days, 90 days, 1 year, 5 years and 10 years after THA; (2) identify risk factors and causes of mortality after THA.

METHODS

Pubmed, MEDLINE, Cochrane, EBSCO Host, and Google Scholar databases were queried for studies reporting mortality rates after primary elective, unilateral THA. Inverse-proportion models were constructed to quantify the incidence of all-cause mortality at 30 days, 90 days, 1 year, 5 years and 10 years after THA. Random-effects multiple regression was performed to investigate the potential effect modifiers of age (at time of THA), body mass index, and gender.

RESULTS

A total of 53 studies (3,297,363 patients) were included. The overall mortality rate was 3.9%. The 30-day mortality was 0.49% (95% CI; 0.23-0.84). Mortality at 90 days was 0.47% (95% CI, 0.38-0.57). Mortality increased exponentially between 90 days and 5 years, with a 1-year mortality rate of 1.90% (95% CI, 1.22-2.73) and a 5-year mortality rate of 9.85% (95% CI, 5.53-15.22). At 10-year follow-up, the mortality rate was 16.43% (95% CI, 1.17-22.48). Increasing comorbidity indices, socioeconomic disadvantage, age, anaemia, and smoking were found to be risk factors for mortality. The most commonly reported causes of death were ischaemic heart disease, malignancy, and pulmonary disease.

CONCLUSIONS

All-cause mortality remains low after contemporary THA. However, 1 out of 10 patients and 1 out of 6 patients were deceased after 5 years and 10 years of THA, respectively. As expected, age, but not BMI or gender, was significantly associated with mortality.

90-day outcomes and factors for complications following radial head arthroplasty for Mason Type III and IV radial head fractures

PURPOSE

The aim of this study is to evaluate 90-day outcomes and complications following radial head arthroplasty (RHA) for Mason Type III and IV radial head fractures (RHFs) and determine factors predisposing patients to early complications and revision surgery.

METHODS

Patients undergoing RHA for Mason Type III and IV RHFs were identified retrospectively from an institutional database. Postoperative complications, reoperations, elbow range of motion, radiographs and concomitant injuries on the ipsilateral upper extremity were reviewed. Additionally, injuries were sub-classified as low-energy trauma (LET) or high-energy trauma (HET). Univariate logistic regression was performed to evaluate the risk for complications using patient factors not limited to the presence of concomitant ligamentous or bony injuries. P values < 0.05 were considered statistically significant.

RESULTS

Seventy four patients were included in our study with an average follow-up time of 12.7 months. Complications within 90-days of operation occurred in 8.1% of patients: heterotopic ossification (4.1%), superficial wound dehiscence (2.7%), and posterior interosseous nerve palsy (1.4%). No patients required readmission or revision surgery in the 90-day postoperative period. Univariate regression analysis did not demonstrate a significant association between diabetes, ASA status, HET versus LET, or the presence of concomitant injury. Concomitant injuries were found in 92% of patients.

CONCLUSION

Radial head arthroplasty for RHFs demonstrates a low complication rate in the short-term. Diabetes, ASA class, high versus low energy trauma, and presence of concomitant injury were not found to be associated with higher complication rates in the 90-day postoperative period.

LEVEL OF EVIDENCE

Level of evidence IV, retrospective case series.

Is a Higher Number of Total Hip and Knee Arthroplasty Revisions Associated With Increased Mortality?

BACKGROUND

It remains uncertain whether patients who undergo numerous total hip arthroplasty (THA) and/or knee arthroplasty (TKA) revisions exhibit decreased survival. Therefore, we sought to determine if the number of revisions per patient was a mortality predictor.

METHODS

We retrospectively reviewed 978 consecutive THA and TKA revision patients from a single institution (from January 5, 2015-November 10, 2020). Dates of first-revision or single revision during study period and of latest follow-up or death were collected, and mortality was assessed. Number of revisions per patient and demographics corresponding to first revision or single revision were determined. Kaplan-Meier, univariate, and multivariate Cox-regressions were utilized to determine mortality predictors. The mean follow-up was 893 days (range, 3-2,658).

RESULTS

Mortality rates were 5.5% for the entire series, 5.0% among patients who only underwent TKA revision(s), 5.4% for only THA revision(s), and 17.2% for patients who underwent TKA and THA revisions (P = .019). In univariate Cox-regression, number of revisions per patient was not predictive of mortality in any of the groups analyzed. Age, body mass index (BMI), and American Society of Anesthesiologists (ASA) were significant mortality predictors in the entire series. Every 1 year of age increase significantly elevated expected death by 5.6% while per unit increase in BMI decreased the expected death by 6.7%, ASA-3 or ASA-4 patients had a 3.1 -fold increased expected death compared to ASA-1 or ASA-2 patients.

CONCLUSION

The number of revisions a patient underwent did not significantly impact mortality. Increased age and ASA were positively associated with mortality but higher BMI was negatively associated. If health status is appropriate, patients can undergo multiple revisions without risk of decreased survival.

Managing early complications in total hip arthroplasty: the safety of immediate revision

PURPOSE

Immediate revision refers to a reoperation that involves resetting, draping, and exchanging the implant, after wound closure in total hip arthroplasty. The purpose of this study is to investigate the impact of immediate revision after total hip arthroplasty on subsequent infection and complication rates.

METHODS

A total of 14,076 primary total hip arthroplasties performed between 2010 and 2020 were identified in our institutional database, of which 42 underwent immediate revision. Infection rates were determined 2 years after the index arthroplasty. The cause and type of revision, duration of primary and revision surgeries, National Nosocomial Infections Surveillance score, implant type, changes in implants, complications, and preoperative and intraoperative antibiotic prophylaxis were all determined.

RESULTS

No infections were observed within 2 years after the index arthroplasty. Leg length discrepancy (88%, n = 37) and dislocation (7.1%, n = 3) were the main causes of immediate revision. In most cases of discrepancy, the limb was clinically and radiologically longer before the immediate revision. The mean operative time was 48 ± 14 min for the primary procedure and 23.6 ± 9 min for the revision. The time between the first incision and last skin closure ranged from 1 to 3 h. None of the patients were extubated between the two procedures. Two patients had a National Nosocomial Infections Surveillance score of 2, 13 had a score of 1, and 27 had a score of 0.

CONCLUSION

Immediate revision is safe for correcting clinical and radiological abnormalities, and may not be associated with increased complication or infection rates.

STUDY DESIGN

Retrospective cohort study; level of evidence, 3.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study

BACKGROUND

It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort.

METHODS

All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions.

RESULTS

The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort.

CONCLUSION

Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.

Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes, Complications, and Healthcare Utilizations (2010 to 2020)

BACKGROUND

The removal of total knee arthroplasty (TKA) from inpatient-only lists accelerated changes in orthopaedic surgical practices across the United States. This study aimed to (1) quantify the annual volume of inpatient/outpatient primary TKAs; (2) compare patient characteristics before/after the year 2018; and (3) compare annual trends in 30-day readmissions, 30-day complications, and healthcare utilization parameters for inpatient/outpatient TKAs.

METHODS

The National Surgical Quality Improvement Program was reviewed (January 2010 to December 2020) for patients who underwent primary TKA (n = 470,456). The primary outcome was annual volumes of inpatient/outpatient TKA. Secondary outcomes included 30-day readmissions, 30-day reoperations, and 30-day major/minor complications. Demographic characteristics and healthcare utilization parameters (hospital lengths of stay and discharge dispositions) were compared between cohorts via Chi-square goodness-of-fit tests.

RESULTS

Overall, 89% had inpatient TKA (n = 416,972) and 11% had outpatient TKA (n = 53,854). Between 2017 and 2020, annual volumes of outpatient TKA increased by 1,925 (1,019 to 20,633), while inpatient TKA decreased by 53% (61,874 to 29,280). Patients who had outpatient TKA after 2018 were older (P < .001), predominantly males (P < .001), more commonly White (P < .001), and had a greater proportion of American Society of Anesthesiologists class III (P < .001). The inpatient cohort had higher rates of 30-day readmissions, reoperations, and complications. Average length of stay and nonhome discharges decreased for both cohorts.

CONCLUSION

Outpatient TKA increased 20-fold at NSQIP hospitals. The changes in comorbidity profiles and the increase in volumes of outpatient TKA were not associated with a rise in cumulative 30-day readmissions and complications. Further research and policy endeavors should focus on identifying patients who still require or benefit from inpatient TKA.