Higher rates of surgical and medical complications and mortality following TKA in patients aged ≥ 80 years: a systematic review of comparative studies

Factors influencing the decision to receive total knee replacement among patients with severe knee osteoarthritis under universal health insurance coverage

This study aimed to investigate the factors influencing the decision of patients with severe knee osteoarthritis, who are covered by universal health insurance, to undergo total knee replacement (TKR) surgery, as recommended by orthopedic physicians. A questionnaire survey was used to collect participants' demographics, socio-economic status, medical history, baseline Oxford Knee Score (OKS), and EuroQol-5 Dimension Questionnaire (EQ-5D). We included 704 patients with severe knee osteoarthritis, of which 487 underwent TKR (surgery group), while 217 did not (non-surgery group). Descriptive statistics was used to compare the characteristics of patients in the two groups, while logistic regression identified the factors influencing patients' choice for TKR. Patients aged 75-79 or older were less likely to undergo TKR; those with poorer OKS (OR = 0.83, 95% CI: 0.79-0.86) and lower EQ-5D VAS scores (OR = 0.97, 95% CI: 0.95-0.99) were more likely to undergo TKR. Household income did not significantly affect the decision of the patients to undergo surgery. In conclusion, for patients with severe knee osteoarthritis, the impact of joint discomfort on function and quality of life is the primary factor influencing their decision to undergo TKR, while economic factors do not have a significant impact under the provision of universal health insurance coverage.

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.

Patient experiences with a smartphone application dedicated to postoperative recovery after elective arthroplasty

Introduction

In the rapidly evolving landscape of digital health technologies, the widespread use of smartphones has paved the way for innovative applications designed to enhance healthcare experiences. This introduction underscores the global prevalence of smartphone users and their potential in healthcare, particularly exemplified by therapeutic apps such as the 'Post Op' smartphone application. Focused on postoperative support, this app prioritises user-friendly design, data recording, and adherence to national standards. The study aims to evaluate the app's success in achieving these objectives, highlighting its continuous improvement based on real user feedback and its potential impact on improving patient experiences and recovery processes.

Methods and materials

A cohort of elective joint arthroplasty procedure patients at Kettering General Hospital (KGH), spanning a timeframe of one to 12 months post-surgery were surveyed over the telephone regarding their experience of the 'Post Op' smartphone utilising a custom, well-structured standardised questionnaire.

Results

The study surveyed 42 consecutive patients who had undergone elective joint arthroplasty procedures at Kettering General Hospital, including 22 total hip replacement (THR) and 20 total knee replacement (TKR) patients. The respondents, with a median age of 66 years, provided overwhelmingly positive feedback about the 'Post Op' smartphone application. On a scale of 1-6, the mean ease-of-use score was 5.31, with only two THR patients providing lower scores due to difficulties with photography. However, the app's overall functionality, particularly in uploading photos, received a mean score of 4.78. Despite some technical issues, 97.6 % of respondents would recommend the app, emphasising its positive impact on confidence in the recovery and reducing unnecessary healthcare visits. Narrative responses highlighted the app's simplicity, support, and prompt communication with healthcare teams. Overall, the feedback indicates a high level of satisfaction with the 'Post Op' application among elective arthroplasty patients, showcasing its potential benefits for postoperative care.

Conclusion

The study provides valuable insights into the impact of the 'Post Op' smartphone application on postoperative care, acknowledging both its successes and areas for enhancement. Further research and iterative improvements are crucial for optimising patient experiences and ensuring the app aligns effectively with healthcare needs.

Unicompartmental knee arthroplasty in octogenarians: An analysis of 1,466 patients with 2-year follow-up

INTRODUCTION

Unicompartmental knee arthroplasty (UKA) has been shown to improve pain and function in appropriately selected patients. Limited data exists regarding outcomes and complication rates following UKA among octogenarians.

METHODS

The PearlDiver Mariner database was queried for patients undergoing primary UKA between 2010-2022. Patients < 80 years old were matched 4:1 to the octogenarian cohort (≥80 years old) by sex, year, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 1,334 octogenarians and 5,313 controls were included in our analysis. Multivariate logistic regression was utilized to compare medical complications at 90-days post-operatively and surgical complications at 1- and 2-years post-operatively. Our regression analysis controlled for sex, ECI, tobacco use, obesity, and diabetes.

RESULTS

Octogenarians had an increased risk of acute kidney injury (OR: 2.306, 95% CI: 1.393-3.749; p < 0.001), pneumonia (OR: 2.367, 95% CI: 1.301-4.189; p = 0.003), UTI (OR: 1.846, 95% CI: 1.304-2.583; p < 0.001), ED visits (OR: 2.229, 95% CI: 1.586-3.105; p < 0.001), and any complication (OR: 1.575, 95% CI: 1.304-1.895; p < 0.001) at 90-days post-operatively. Octogenarians had lower odds of all-cause revision at 2-years (OR: 0.607, 95% CI: 0.382-0.923; p = 0.026). No differences were demonstrated between cohorts in rates of PJI (OR: 0.832, 95% CI: 0.334-1.796; p = 0.664), periprosthetic fracture (OR: 0.516, 95% CI: 0.120-1.520; p = 0.289), or aseptic loosening (OR: 0.285, 95% CI: 0.045-1.203; p = 0.088) at 2-years.

DISCUSSION

These findings suggest that despite an increased risk of certain medical complications within the acute post-operative period, octogenarians undergoing UKA experienced similar rates of surgical complications to younger matched controls at 2-year follow-up.

Effect of low-intensity muscle strength training on postoperative rehabilitation and adverse events in patients with knee osteoarthritis over 55 years of age: a meta-analysis

BACKGROUND

This study aimed to study the effect of low-intensity muscle strength training on postoperative rehabilitation of patients with knee osteoarthritis over 55 years of age and the incidence of adverse events by a meta-analysis.

METHODS

We searched China National Knowledge Infrastructure (CNKI), WanFang, China Science and Technology Journal Database (VIP), PubMed, Web of science, and Embase databases for articles on the effect of low-intensity muscle strength training on the recovery of patients with knee arthritis. And meta-analysis combined effect was performed in R 4.2.2 software. Quantitative analysis and risk of bias were assessed by Begg's and Eegger's test.

RESULTS

Meta-analysis showed that the effect of low-intensity muscle strength training on postoperative knee range of motion in patients with knee arthritis was mean difference (MD) = 5.20, 95% CI=[4.00, 6.40], τ2 = 0.43, P = 0.34; the effect on postoperative muscle strength was standard mean difference (SMD) = 1.24, 95% CI=[0.86, 1.61], τ2 = 0.07, P < 0.01; the effect on postoperative knee joint score was MD = 5.88, 95%CI=[2.09, 9.67], τ2 = 16.60, P < 0.01; the effect on postoperative knee visual analogue scale (VAS) score was MD=-1.12, 95%CI =[-1.43, -0.81], τ2 = 0.09, P < 0.001; the effect on the incidence of adverse events was RR = 0.85, 95%CI= [0.52 1.39], τ2 = 0.79, P = 0.04.

CONCLUSION

Low-intensity muscle strength training can improve the muscle strength of the affected limb and knee joint score, reduce the VAS score and the incidence of adverse events in patients with knee osteoarthritis over 55 years of age after surgery, but it has no effect on the postoperative knee range of motion, so it can be considered as appropriate in clinical selection.

Progress in Computer-Assisted Navigation for Total Knee Arthroplasty in Treating Knee Osteoarthritis with Extra-Articular Deformity

Total knee arthroplasty (TKA) is a well-established treatment for end-stage knee osteoarthritis. However, in patients with concomitant extra-articular deformities, conventional TKA techniques may lead to unsatisfactory outcomes and higher complication rates. This review summarizes the application of navigated TKA for treating knee osteoarthritis with extra-articular deformities. The principles and potential benefits of computer navigation systems, including improved component alignment, soft tissue balancing, and restoration of mechanical axis, are discussed. Research studies demonstrate that navigated TKA can effectively correct deformities, relieve pain, and improve postoperative joint function and quality of life compared with conventional methods. The advantages of navigated TKA in terms of surgical precision, lower complication rates, and superior functional recovery are highlighted. Despite challenges like the learning curve and costs, navigated TKA is an increasingly indispensable tool for achieving satisfactory outcomes in TKA for knee osteoarthritis patients with extra-articular deformities.

Perioperative and frailty outcomes after total knee arthroplasty: a retrospective cohort study

BACKGROUND

Total knee arthroplasty (TKA) is a common procedure with an increasing demand, especially among the elderly. Frailty is known to be associated with adverse perioperative outcomes in the older population. In this article, we aimed to understand the associations of preoperative frailty status and comorbid conditions in relation to their clinical and healthcare outcomes after TKA, and to describe the perioperative factors leading to improvement in a patient's frailty status after TKA.

METHODS

This is a retrospective cohort study, and the outcomes were assessed over 2 years. Frailty is defined by the Clinical Frailty Score.

RESULTS

A total of 96 patient records were assessed, of which 13 (13.5%) patients were robust and 83 (86.5%) patients were prefrail or frail. Two years after TKA, the number of robust patients increased to 58 (61.7%) patients, showing a reversal of frailty in 48.2% of patients.

CONCLUSION

Total knee arthroplasty in prefrail and frail patients is a safe procedure that leads to improvement of frailty status, with an increase in the proportion of patients becoming robust within 2 years after the operation.

Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

BACKGROUND

The optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA.

METHODS

Using an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience.

RESULTS

The risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B].

CONCLUSIONS

Chronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

The Impact of Tranexamic Acid on Blood Loss Management in Primary Total Knee Arthroplasty: A Comprehensive Review

Total knee arthroplasty (TKA) is a widely performed surgical procedure to restore function and relieve pain in patients with advanced knee arthritis. One of the key challenges in TKA is managing perioperative blood loss, which can lead to complications such as postoperative anemia and the need for blood transfusions. Tranexamic acid (TXA), an antifibrinolytic agent, has shown promising results in reducing blood loss and transfusion requirements in various surgical settings, including TKA. This comprehensive review synthesizes current evidence regarding the efficacy and safety profile of TXA in primary TKA. Mechanistically, TXA functions by inhibiting the breakdown of fibrin clots, promoting hemostasis, and minimizing blood loss. Clinical studies evaluating TXA in TKA have consistently demonstrated significant reductions in blood loss parameters, including total blood loss, postoperative drain output, and transfusion rates. Key findings highlight the efficacy of TXA across different dosing regimens and administration routes, with minimal associated risks of thromboembolic events or adverse effects. Comparative analyses with other blood conservation strategies underscore TXA's superiority in reducing transfusion requirements and its cost-effectiveness in clinical practice. The review also discusses current clinical guidelines and recommendations for TXA use in TKA, emphasizing optimal dosing strategies and patient selection criteria. Future research directions include exploring the long-term outcomes of TXA administration and its impact on functional recovery, and refining protocols to enhance its efficacy and safety further. In conclusion, TXA represents a valuable adjunct in blood loss management during primary TKA, offering substantial benefits in patient outcomes, healthcare resource utilization, and cost-effectiveness. Continued research efforts are warranted to optimize its use and expand its applicability in orthopedic surgery.

A Lack of Generalizability-Total Knee Demographics in the Active Duty Population

INTRODUCTION

Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes.

METHODS

A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann-Whitney U test, and gender was compared with a chi-squared test.

RESULTS

During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P < .001) and younger (P < .001).

CONCLUSION

Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System.

Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people

BACKGROUND

age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth.

OBJECTIVE

to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures.

PATIENTS AND METHODS

retrospective health insurance data from January 2008 to December 2019 of patients ≥65 years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models.

RESULTS

a total of 43,310 patients (median age 79 years, 84.4% female) with a median follow-up of 40.9 months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk.

CONCLUSIONS

a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.

Similar survival rate but lower functional outcomes following TKA in the elderly people compared to younger patients: analysis of a posterior stabilised implant with minimum 5-year follow-up

BACKGROUND

Literature regarding outcomes in patients over 80 years old after total knee arthroplasty (TKA) is inconsistent. We aimed to compare implant survivorship and functional outcomes between elderly patients (≥ 80 years) and younger patients (< 80 years) following TKA, using a single modern posterior-stabilized (PS) prosthetic design.

METHODS

This is a retrospective cohort study of 80 patients over 80 years old who underwent TKA between January 2015 and December 2016, who were compared with younger patients (60-75 years old) operated during the same period. Patients were matched with a ratio of 1:3 based on logistic regression analysis of gender and body mass index. All patients received the same cemented PS prosthesis with a fixed bearing polyethylene insert, with or without patellar resurfacing. Implant survival and patient-reported outcome measurements were compared between the two groups. At last follow-up, data were available for 41 knees in the elderly group (including 17 patients who died before 5-year follow-up) and 123 knees in the younger group.

RESULTS

Functional results were better at final follow-up in the group < 80 years with a significantly higher Knee Society Function Subscore (88.6 ± 16.9 vs 79.4 ± 22.1, p < 0.01), but no significant differences in Knee Subscore and global Knee Society Score (p > 0.05), nor regarding maximum flexion (121° ± 12 and 117° ± 13, p = 0.08). The implant survivorship was 100.0% after a mean 64.4-month follow-up (range 60-78), without revision requiring removal of the implant in any group. The survival rate without any reoperation was 97.6% (95% CI 93.0-100.0) in the elderly group and 95.9% (95% CI 92.5-99.5) in the younger group (p = 0.64).

CONCLUSION

At a minimum of 5-year follow-up, there was no revision surgery and a very low rate of complications requiring reoperations both in the group over 80 years of age and in the younger population, with the use of a PS prosthesis. The functional results were slightly lower for elderly patients and correlate with the lower functional demands of this population. The indication for TKA, especially with a PS implant, may be encouraged in appropriately selected elderly patients.

LEVEL OF EVIDENCE

III (retrospective cohort study).

Development and validation of a nomogram to predict complications in patients undergoing simultaneous bilateral total knee arthroplasty: A retrospective study from two centers

Purpose

Complications were significantly increased 30 days after Simultaneous bilateral total knee arthroplasty (SBTKA). In this study, an individualized nomogram was established and validated to predict the complications within 30 days after SBTKA.

Methods

The general data of 861 patients (training set) who received SBTKA in The Affiliated Hospital of Qingdao University between January 1, 2012 and March 31, 2017 were retrospectively analyzed. All patients were divided into complication group (n = 96) and non-complication group (n = 765) according to the incidence of complications within 30 years after SBTKA. Independent risk factors for postoperative SBTKA complications were identified and screened by binary logistic regression analyses, and then a nomogram prediction model was constructed using R software. The area under curve (AUC), calibration curve, and decision curve analysis (DCA) were selected to evaluate the line-chart. Meanwhile, 396 patients receiving SBTKA in the Third Hospital of Hebei Medical University who met the inclusion and exclusion criteria (test set) were selected to verify the nomogram.

Results

Five independent predictors were identified by binary logistic regression analyses and a nomogram was established. The AUC of this nomogram curve is 0.851 (95% CI: 0.819-0.883) and 0.818 (95% CI: 0.735-0.900) in the training and testing sets, respectively. In the training set and test set, calibration curves show that nomogram prediction results are in good agreement with actual observation results, and DCA shows that nomogram prediction results have good clinical application value.

Conclusion

Older age, lower preoperative hemoglobin level, higher preoperative blood urea nitrogen (BUN) level, longer operation time, ASA grade ≥ III are independent predictors of SBTKA complications within 30 days after surgery. A nomogram containing these five predictors can accurately predict the risk of complications within 30 days after SBTKA.