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Bloom DA, Bieganowski T, Robin JX, Arshi A, Schwarzkopf R, Rozell JC. Evaluation of Preoperative Variables that Improve the Predictive Accuracy of the Risk Assessment and Prediction Tool in Primary Total Hip Arthroplasty. J Am Acad Orthop Surg 2024:00124635-990000000-00987. [PMID: 38754131 DOI: 10.5435/jaaos-d-23-00784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Discharge disposition after total joint arthroplasty may be predictable. Previous literature has attempted to improve upon models such as the Risk Assessment and Prediction Tool (RAPT) in an effort to optimize postoperative planning. The purpose of this study was to determine whether preoperative laboratory values and other previously unstudied demographic factors could improve the predictive accuracy of the RAPT. METHODS All patients included had RAPT scores in addition to the following preoperative laboratory values: red blood cell count, albumin, and vitamin D. All values were recorded within 90 days of surgery. Demographic variables including marital status, American Society of Anesthesiologists (ASA) scores, body mass index, Charlson Comorbidity Index, and depression were also evaluated. Binary logistic regression was used to determine the significance of each factor in association with discharge disposition. RESULTS Univariate logistic regression found significant associations between discharge disposition and all original RAPT factors as well as nonmarried patients (P < 0.001), ASA class 3 to 4 (P < 0.001), body mass index >30 kg/m2 (P = 0.065), red blood cell count <4 million/mm3 (P < 0.001), albumin <3.5 g/dL (P < 0.001), Charlson Comorbidity Index (P < 0.001), and a history of depression (P < 0.001). All notable univariate models were used to create a multivariate model with an overall predictive accuracy of 90.1%. CONCLUSIONS The addition of preoperative laboratory values and additional demographic data to the RAPT may improve its PA. Orthopaedic surgeons could benefit from incorporating these values as part of their discharge planning in THA. Machine learning may be able to identify other factors to make the model even more predictive.
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Affiliation(s)
- David A Bloom
- From the Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Mansour E, Boddu SP, Gill VS, Abu Jawdeh BG, McGary AK, Clarke HD, Spangehl MJ, Abdel MP, Ledford CK, Bingham JS. Risk Factors in Patients Who Had Prior Renal or Liver Transplant Undergoing Primary Total Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(23)01173-7. [PMID: 38048964 DOI: 10.1016/j.arth.2023.11.030] [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: 09/10/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND More solid organ transplant (SOT) patients are undergoing total knee arthroplasty (TKA). This study identifies risk factors for complications, implant survivorship, and mortality in TKA patients who had prior SOT. METHODS We identified 176 TKAs in patients who had prior SOT. Of these, 77 had a prior renal (RT), 77 had a prior liver (LT) transplant, and 22 had multiple prior transplants (MT). Median survival was estimated using Kaplan-Meier. Univariate analyses were assessed with mixed-effects logistic regressions for complications and Cox-regressions for mortality. Median follow-up was 63 months (range, 24 to 109). RESULTS At least one acute medical complication occurred in 25, 13, and 27% of cases with prior RT, LT, and MT, respectively (P = .12). None of the variables were significantly associated with acute medical complications. At least one surgical complication occurred in 14, 13 and 14% of cases with prior RT, LT, and MT, respectively (P = 1). Vitamin D supplementation (Odds Ratio [OR] = 0.38, P < .03) was associated with lower risk of surgical complications. Reoperation and revision rates were 5 and 3%, respectively. Older age at time of transplantation and greater level of serum creatinine at time of TKA were associated with lower risk (OR = 0.96, P = .01), and higher risk of reoperation (OR = 4.9, P = .01), respectively. Coronary artery disease was associated with higher mortality (Hazard Ratio = 2.35, P = .01). CONCLUSIONS Vitamin D was associated with lower surgical complications, whereas a younger age at time of transplantation increased the risk of reoperation. Additionally, SOT patients with coronary artery disease demonstrated higher mortality after TKA.
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Affiliation(s)
- Elie Mansour
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Sayi P Boddu
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Vikram S Gill
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | | | - Alyssa K McGary
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona
| | - Henry D Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cameron K Ledford
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
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Mouli VH, Schudrowitz N, Carrera CX, Uzosike AC, Fitz W, Rajaee SS. High-Dose Vitamin D Supplementation Can Correct Hypovitaminosis D Prior to Total Knee Arthroplasty. J Arthroplasty 2022; 37:274-278. [PMID: 34737019 DOI: 10.1016/j.arth.2021.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/03/2021] [Accepted: 10/25/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vitamin D deficiency in the perioperative surgical period is associated with inferior surgical outcomes. There are no established preoperative supplementation regimens in the orthopedic literature. The purpose of this study is to compare the efficacy between 2 different supplementation regimens of vitamin D prior to total knee arthroplasty. METHODS We conducted a retrospective analysis of 174 patients identified as vitamin D deficient (25(OH)D < 30 ng/mL) who received one of 2 vitamin D supplementation protocols: (1) daily supplementation with D3 on a sliding scale from 1000 to 6000 IU or (2) a loading dose of 50,000 IU D3 weekly for 4 weeks then 2000 IU/d. Serum vitamin D levels were measured at 3 months and 1 month preoperatively. RESULTS Mean patient age was 65.5(±8.6) years, and 54.6% were female. Deficiency was corrected in 73.3% of patients in the loading dose group and 42.4% of patients in the daily, low-dose group [χ2 (1, N = 174) = 16.53, P < .001]. Patients in the loading dose group also achieved a greater average correction in vitamin D levels. CONCLUSION This is the first study to compare preoperative vitamin D supplementation protocols. A loading dose regimen of 50,000 IU weekly for 4 weeks followed by a maintenance dose of 2000 IU/d more effectively corrects vitamin D deficiency compared to a low-dose, daily regimen among total knee arthroplasty patients. We recommend this regimen for deficiency correction in patients who have been screened to be deficient in vitamin D preoperatively.
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Affiliation(s)
- Vibav H Mouli
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Wolfgang Fitz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Sean S Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Moran MM, Wessman P, Rolfson O, Bohl DD, Kärrholm J, Keshavarzian A, Sumner DR. The risk of revision following total hip arthroplasty in patients with inflammatory bowel disease, a registry based study. PLoS One 2021; 16:e0257310. [PMID: 34735461 PMCID: PMC8568118 DOI: 10.1371/journal.pone.0257310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the intestinal tract and is associated with decreased bone mineral density. IBD patients are at higher risk of osteopenia, osteoporosis and fracture compared to non-IBD patients. The impact of IBD on the performance of orthopedic implants has not been well studied. We hypothesized that a history of IBD at the time of primary total hip arthroplasty (THA) would increase the risk of subsequent failure as assessed by revision surgery. A retrospective implant survival analysis was completed using the Swedish Hip Arthroplasty Registry and the Sweden National Patient Register. A total of 150,073 patients undergoing THA for osteoarthritis within an 18-year period were included in the study. THA patients with (n = 2,604) and without (n = 147,469) a history of IBD at the time of THA were compared with primary revision as the main endpoint and adjusted using sex, age category and comorbidity (Elixhauser scores) as covariates. We found that patients with a history of IBD had a relatively higher risk of revision surgery for septic causes while the non-IBD patients had a relatively higher risk of revision for aseptic causes (p = 0.004). Our findings suggest there may be an association between gut health and THA performance.
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Affiliation(s)
- Meghan M. Moran
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Peter Wessman
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel D. Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States of America
| | - Johan Kärrholm
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ali Keshavarzian
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Rush Medical College, Chicago, IL, United States of America
| | - D. Rick Sumner
- Department of Cell & Molecular Medicine, Rush University Medical Center, Chicago, IL, United States of America
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States of America
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Brambilla L, Peretti GM, Sirtori P, Maffulli N, Mangiavini L. Outcome of total hip and total knee arthroplasty and vitamin D homeostasis. Br Med Bull 2020; 135:50-61. [PMID: 32776138 DOI: 10.1093/bmb/ldaa018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Low levels of vitamin D are common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), but it is still unclear whether the outcome of such surgery is related to vitamin D levels. SOURCES OF DATA Publicly available electronic databases were systematically reviewed to update knowledge about the role of vitamin D in THA and TKA patients, and to appraise the correlation between vitamin D levels before surgery and post-surgical outcomes. Eight studies were included in our review: six employed prospective observational designs, two reported retrospective database interrogations. Six prospective observational studies and two retrospective database interrogations matched inclusion and exclusion criteria. AREAS OF AGREEMENT Patients undergoing THA and TKA have a high prevalence of hypovitaminosis D. Five of eight studies (62.5%) report a statistically significant association between low vitamin D status and worse outcomes after THA and TKA. AREAS OF CONTROVERSY Different explanations have been proposed for vitamin D insufficiency, but some authors have questioned the correctness of the methods used to measure the vitamin D levels. GROWING POINTS A trial focusing on the role of vitamin D supplementation on safety and outcomes of patients undergoing THA and TKA with low vitamin D status is ongoing. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies should explore the possible causal relationship between vitamin D status and outcomes of THA and TKA and verify the laboratory methods to analyse it.
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Affiliation(s)
- Lorenzo Brambilla
- Residency Program in Orthopaedics and Traumatology, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Giuseppe Maria Peretti
- University Equipe of Regenerative and Reconstructive Orthopaedics (EUORR), IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161 Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Paolo Sirtori
- University Equipe of Regenerative and Reconstructive Orthopaedics (EUORR), IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161 Milan, Italy
| | - Nicola Maffulli
- San Giovanni di Dio e Ruggi D'Aragona Hospital, "Clinica Ortopedica" Department, Hospital of Salerno, Via San Leonardo, 84125 Salerno, Italy.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
| | - Laura Mangiavini
- University Equipe of Regenerative and Reconstructive Orthopaedics (EUORR), IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161 Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
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Arshi A, Shieh A, Adams JS, Bernthal NM, Zeegen EN, Sassoon AA. Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model. J Arthroplasty 2020; 35:1379-1383. [PMID: 31983566 DOI: 10.1016/j.arth.2019.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA). METHODS A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion. RESULTS Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%. CONCLUSION This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.
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Affiliation(s)
- Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Albert Shieh
- Division of Geriatrics, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - John S Adams
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Erik N Zeegen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Adam A Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Visser E, de Roos NM, Oosting E, Endenburg SC, Dronkers JJ. Association Between Preoperative Vitamin D Status and Short-Term Physical Performance after Total Hip Arthroplasty: A Prospective Study. ANNALS OF NUTRITION AND METABOLISM 2018; 73:252-260. [PMID: 30253382 DOI: 10.1159/000492938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Insufficient serum vitamin D concentrations (50-75 nmol/L) are prevalent in 40-65% of patients who require total hip arthroplasty (THA). This could impair physical recovery after surgery. This study investigated the association between preoperative vitamin D status and physical performance after THA. Additionally, postoperative changes in vitamin D concentrations were measured. METHODS We included 87 patients scheduled for elective THA and aged ≥65 years. Three groups were recruited: patients classified as vitamin D deficient (< 50 nmol/L, n = 23), insufficient (50-75 nmol/L, n = 32), or sufficient (> 75 nmol/L, n = 32). Serum 25-hydroxyvitamin D3 (25[OH]D3) concentration and physical performance were measured perioperatively. Linear mixed models were used to examine differences between groups. RESULTS Change in physical performance over time was not affected by preoperative vitamin D status. In contrast, for physical activity, both vitamin D (p = 0.021) and time (p < 0.001) effect was seen: from 80.2 ± 25.8 to 58.1 ± 17.8 min/day in the deficient group, 143.7 ± 19.8 to 92.9 ± 11.5 min/day in the insufficient group, and 108.1 ± 20.9 to 62.3 ± 12.9 min/day in the sufficient group. The Chair Stand Test, Timed Up and Go test, and 10-Meter Walking Test also improved significantly over time, but independent of vitamin D status. An increase in 25(OH)D3 concentration 6 weeks postoperatively was correlated with improved hip function (Pearson's r = -0.471, p = 0.018). Overall, serum 25(OH)D3 declined with 32% one day after surgery (p < 0.001), to nearly return to baseline values 6 weeks later in all groups. CONCLUSION Vitamin D status did not appear to affect physical recovery after THA. The drop in vitamin D after surgery deserves further investigation, but could possibly be explained by hemodilution.
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Affiliation(s)
- Edith Visser
- Division of Human Nutrition, Wageningen University, Wageningen, the Netherlands
| | - Nicole M de Roos
- Division of Human Nutrition, Wageningen University, Wageningen, the Netherlands
| | - Ellen Oosting
- Department of Physical Therapy, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Silvia C Endenburg
- Department of Clinical Chemistry and Hematology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Jaap J Dronkers
- Department of Physical Therapy, Gelderse Vallei Hospital, Ede, the Netherlands
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