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Gysling S, Lewis-Lloyd CA, Lobo DN, Crooks CJ, Humes DJ. The effect of diabetes mellitus on perioperative outcomes after colorectal resection: a national cohort study. Br J Anaesth 2024; 133:67-76. [PMID: 38760264 PMCID: PMC11213983 DOI: 10.1016/j.bja.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Diabetes mellitus is a significant modulator of postoperative outcomes and is an important risk factor in the patient selection process. We aimed to investigate the effect of diabetes mellitus and use of insulin on outcomes after colorectal resection using a national cohort. METHODS Adults with a recorded colorectal resection in England between 2010 and 2020 were identified from Hospital Episode Statistics data linked to the Clinical Practice Research Database. The primary outcome was 90-day mortality. Secondary outcomes included hospital length of stay (LOS) and readmission within 90 days. RESULTS Of the 106 139 (52 875, 49.8% male) patients included, diabetes mellitus was prevalent in 10 931 (10.3%), 2145 (19.6%) of whom had a record of use of insulin. Unadjusted 90-day mortality risk was 5.7%, with an increased adjusted hazard ratio (aHR) for people with diabetes mellitus (aHR 1.28, 95% confidence interval [CI] 1.19-1.37, P<0.001). This risk was higher in both people with diabetes using insulin (aHR 1.51, 95% CI 1.31-1.74, P<0.001) and not using insulin (aHR 1.22, 95% CI 1.13-1.33, P<0.001), compared with those without diabetes. Ninety-day readmission occurred in 20 542 (19.4%) patients and this was more likely in those with diabetes mellitus (aHR 1.23, 95% CI 1.18-1.29, P<0.001). Median (inter-quartile range) LOS was 8 (5-15) days and was higher in people with diabetes mellitus (adjusted time ratio 1.10, 95% CI 1.08-1.11, P<0.001). CONCLUSIONS People with diabetes mellitus undergoing colorectal resection are at a higher risk of 90-day mortality, prolonged LOS, and 90-day readmission, with use of insulin associated with additional risk.
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Affiliation(s)
- Savannah Gysling
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Christopher A Lewis-Lloyd
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Colin J Crooks
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - David J Humes
- Nottingham Digestive Diseases Centre, Division of Translation Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Buddhiraju A, Kagabo W, Khanuja HS, Oni JK, Nikkel LE, Hegde V. Decreased Risk of Readmission and Complications With Preoperative GLP-1 Analog Use in Patients Undergoing Primary Total Joint Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00551-5. [PMID: 38823516 DOI: 10.1016/j.arth.2024.05.079] [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: 02/09/2024] [Revised: 03/15/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND There has been considerable interest in the use of GLP-1 receptor analogs (GLP-1 RAs) for weight optimization in patients undergoing elective arthroplasty. As there is limited data regarding the implications of their use, our study aimed to evaluate the association between preoperative GLP-1 RA use and postoperative outcomes in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS The TrinetX research network was queried to identify all patients undergoing primary THA or TKA between May 2005 and December 2023 across 84 health care organizations. Patients were stratified based on preoperative GLP-1 RA use. Propensity score matching (1:1) was performed to account for baseline differences in demographics, laboratory investigations, and comorbidities. Subsequently, risk ratios were evaluated for postoperative outcomes. RESULTS A total of 268,504 and 386,356 patients underwent THA and TKA, of which 1,044 and 2,095 used preoperative GLP-1 RAs. After matching, GLP-1 RA use was associated with a decreased 90-day risk of periprosthetic joint infection (2.1 versus 3.6%, RR = 0.58, P = .042) and readmission (1.1 versus 2.0%, RR = 0.53, P = .017) following THA and TKA, respectively. There was no difference in the risk of all other outcomes between comparison groups. CONCLUSIONS Preoperative GLP-1 RA use is associated with a 42% decreased risk of periprosthetic joint infection and 47% decreased risk of readmission in the 90-day postoperative period following THA and TKA, respectively, with no difference in other risks, including aspiration. Our findings indicate that GLP-1 RAs may be safe to use in patients undergoing elective arthroplasty; however, further studies are warranted to inform the routine use of GLP-1 RAs for weight management in THA and TKA patients.
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Affiliation(s)
- Anirudh Buddhiraju
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Whitney Kagabo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lucas E Nikkel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wang Y, Jiang Q, Long H, Chen H, Wei J, Li X, Wang H, Xie D, Zeng C, Lei G. Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study. Int J Surg 2024; 110:1347-1355. [PMID: 38320106 PMCID: PMC10942226 DOI: 10.1097/js9.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/10/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Limited studies have examined the benefits of early arthroplasty within 48 h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48 h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns. MATERIALS AND METHODS This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty. RESULTS During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11 731 pairs receiving THA and 13 568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA. CONCLUSION Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.
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Affiliation(s)
| | | | | | - Hu Chen
- Tibet Autonomous Region People’s Hospital, Lhasa, Tibet, People’s Republic of China
| | - Jie Wei
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Health Management Center, Xiangya Hospital
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Xiaoxiao Li
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong
| | | | - Chao Zeng
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Guanghua Lei
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
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Kotzur TM, Singh A, Peng LN, Makhani AA, Seifi A, Moore CC. Comparing Common Risk Assessment Tools to Predict Outcomes in Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00079-2. [PMID: 38336306 DOI: 10.1016/j.arth.2024.01.052] [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: 10/19/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND A number of tools exist to aid surgeons in risk assessment, including the Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Index (ECI), and various measures of frailty, such as the Hospital Frailty Risk Score (HFR). While all of these tools have been validated for general use, the best risk assessment tool is still debated. Risk assessment is particularly important in elective surgery, such as total joint arthroplasty. The aim of this study is to compare the predictive power of the CCI, ECI, and HFR in the setting of total knee arthroplasty (TKA). METHODS All patients who underwent TKA were identified via International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code from the National Readmissions Database, years 2016 to 2019. Patient demographics, perioperative complications, and hospital-associated outcomes were recorded. Receiver operating characteristic (ROC) curves were created and area under the curves (AUCs) evaluated to gauge the predictive capabilities of each risk assessment tool (CCI, ECI, and HFR) across a range of outcomes. RESULTS A total of 1,930,803 patients undergoing TKA were included in our analysis. For mortality, ECI was most predictive (0.95 AUC), while HFR and CCI were 0.75 and 0.74 AUC, respectively. For periprosthetic fractures, ECI was 0.78 AUC, HFR was 0.68 AUC, and CCI was 0.66 AUC. For joint infections, the ECI was 0.78 AUC, the HFR was 0.63 AUC, and the CCI was 0.62 AUC. For 30-day readmission, ECI was 0.79 AUC, while HFR and CCI were 0.6 AUC. For 30-day reoperation, ECI was 0.69 AUC, while HFR was 0.58 AUC and CCI was 0.56 AUC. CONCLUSIONS Our analysis shows that ECI is superior to CCI and HFR for predicting 30-day postoperative outcomes following TKA. Surgeons should consider assessing patients using ECI prior to TKA.
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Affiliation(s)
- Travis M Kotzur
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Aaron Singh
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Lindsey N Peng
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Ahmed A Makhani
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
| | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, Texas
| | - Chance C Moore
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonio, Texas
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Magruder ML, Yao VJH, Rodriguez AN, Ng MK, Piuzzi NS, Mont MA. History of Diabetic Foot Ulcer is Associated With Increased Risk of Prosthetic Joint Infection and Sepsis After Total Joint Arthroplasty. J Arthroplasty 2024; 39:250-254. [PMID: 37536397 DOI: 10.1016/j.arth.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) are common sequelae of diabetes mellitus. Currently, the effect of DFUs on total joint arthroplasty (TJA) outcomes is sparsely evaluated. This study investigated whether DFU patients undergoing TJA increases risk of (1) prosthetic joint infections (PJI), (2) surgical site infections (SSI), (3) sepsis, (4) readmissions, and (5) revisions. METHODS Using PearlDiver, a retrospective query from January 1, 2010 to October 31, 2020 was performed. DFU patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) were included and 1:5 propensity score matched with controls using age, sex, body mass index, and various comorbidities (33,155 TKA patients [DFU = 5,529; control = 27,626]; 17,146 THA patients [DFU = 2,862; control = 14,284]). Outcomes included rates of PJI, SSI, sepsis, readmissions, and revisions. Multivariate logistical regressions calculated odds ratios (ORs), 95% confidence intervals, and P values (P < .001 as significance threshold). RESULTS DFU increased risk of sepsis within 90 days of TKA (OR 4.59; P < .001) and THA (OR 4.87; P < .001). DFU did not increase risk of PJI at 90 days for TKA (OR 0.8; P = .1) or THA (OR 0.85; P = .34) but did by 2 years post-TKA (OR 1.51; P < .001) and THA (OR 1.55; P < .001). Risk of SSI increased in DFU cohort following TKA and THA at 90 days and 2 years and at 90-day readmissions and 2-year revisions. CONCLUSION DFU patients undergoing TJA demonstrated increased risk of postoperative sepsis and PJI. Furthermore, DFU patients demonstrated an increased risk of SSI, readmissions, and revisions. Providers should counsel DFU patients about postoperative risks.
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Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Vincent J H Yao
- Sophie Davis Biomedical Education Program at the CUNY School of Medicine, New York, New York
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Zeng L, Cai H, Qiu A, Zhang D, Lin L, Lian X, Chen M. Risk factors for rehospitalization within 90 days in patients with total joint replacement: A meta-analysis. Medicine (Baltimore) 2023; 102:e35743. [PMID: 37960764 PMCID: PMC10637554 DOI: 10.1097/md.0000000000035743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The risk factors influencing the readmission within 90 days following total joint replacement (TJR) are complex and heterogeneous, and few systematic reviews to date have focused on this issue. METHODS Web of Science, Embase, PubMed, and Chinese National Knowledge Infrastructure databases were searched from the inception dates to December 2022. Relevant, published studies were identified using the following keywords: risk factors, rehospitalization, total hip replacement, total knee replacement, total shoulder replacement, and total joint replacement. All relevant data were collected from the studies that meet the inclusion criteria. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS Of 68,336 patients who underwent TJR, 1,269,415 (5.4%) were readmitted within 90 days. High American Society of Anesthesiologists (ASA) class (OR, 1.502; 95%CI:1.405-1.605; P < .001), heart failure (OR,1.494; 95%CI: 1.235-1.754; P < .001), diabetes (OR, 1.246; 95%CI:1.128-1.377; P < .001), liver disease (OR, 1.339; 95%CI:1.237-1.450; P < .001), drinking (OR, 1.114; 95%CI:1.041-1.192; P = .002), depression (OR, 1.294; 95%CI:1.223-1.396; P < .001), urinary tract infection (OR, 5.879; 95%CI: 5.119-6.753; P < .001), and deep vein thrombosis (OR, 10.007; 95%CI: 8.787-11.396; P < .001) showed statistically positive correlation with increased 90-day readmissions after TJR, but high blood pressure, smoking, and pneumonia had no significant association with readmission risk. CONCLUSION The findings of this review and meta-analysis will aid clinicians as they seek to understand the risk factors for 90-day readmission following TJR. Clinicians should consider the identified key risk factors associated with unplanned readmissions and develop strategies to risk-stratify patients and provide dedicated interventions to reduce the rates of readmission and enhance the recovery process.
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Affiliation(s)
- Liping Zeng
- Department of Orthopaedics, No. 910 Hospital of The Chinese People's Liberation Army Joint Logistic Support Force, Quanzhou, China
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. J Arthroplasty 2023; 38:2193-2201. [PMID: 37778918 DOI: 10.1016/j.arth.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Rheumatol 2023; 75:1877-1888. [PMID: 37746897 DOI: 10.1002/art.42630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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Osorio P, Amenábar D, Salineros M, Zylberberg A. Limiting Factors for Indication of Hip and Knee Arthroplasty in Chile: The International Perception of Risk Initiative. J Arthroplasty 2023; 38:2242-2246.e2. [PMID: 37295626 DOI: 10.1016/j.arth.2023.05.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND An aging population with a resultant higher incidence of osteoarthritis have increased the need for total hip (THA) and knee arthroplasty (TKA) worldwide. The purpose of this study was to explore what medical and social risk factors are considered relevant by Chilean orthopaedic surgeons in decisions regarding indications for THA or TKA. METHODS An anonymous survey was sent to 165 hip and knee arthroplasty surgeons who were members of the Chilean Orthopedics and Traumatology Society. From a total of 165 surgeons, 128 (78%) completed the survey. The questionnaire included demographic data, place of work, and inquired about medical and socioeconomic factors that could affect surgical indications. RESULTS Factors that limited indications for elective THA/TKA included body mass index (81%), elevated hemoglobin A1c (92%), lack of social support network (58%), and low socioeconomic status (40%). Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Of the respondents, 64% believe that some patient populations would benefit from better care if payment systems adjusted for their socioeconomic risk factors. CONCLUSION In Chile, limitations regarding the indication for THA/TKA are most influenced by the presence of modifiable medical risk factors such as obesity, uncompensated diabetes, or malnutrition. We believe that the reason surgeons limit surgeries for such individuals is to promote better clinical outcomes, and not in response to pressure from paying entities. However, low socioeconomic status was perceived to impair the ability to achieve good clinical outcomes by 40% of the surgeons.
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Affiliation(s)
- Pedro Osorio
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Diego Amenábar
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Matías Salineros
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Alejandro Zylberberg
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Care Res (Hoboken) 2023; 75:2227-2238. [PMID: 37743767 DOI: 10.1002/acr.25175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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11
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Romeo PV, Papalia AG, Alben MG, Halpern J, Ferati SR, Larose G, Singh H, Virk MS. 90-day outcomes and factors for complications following radial head arthroplasty for Mason Type III and IV radial head fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3099-3106. [PMID: 37029835 DOI: 10.1007/s00590-023-03532-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/20/2023] [Indexed: 06/19/2023]
Abstract
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.
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Affiliation(s)
- Paul V Romeo
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Aidan G Papalia
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Matthew G Alben
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Joshua Halpern
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Sehar Resad Ferati
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Gabriel Larose
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Hartej Singh
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA
| | - Mandeep S Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 East 20th Street, New York, NY, 10003, USA.
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Li S, Si H, Zhang S, Xu J, Liu Y, Shen B. Does diabetes mellitus impair the clinical results of total knee arthroplasty under enhanced recovery after surgery? J Orthop Surg Res 2023; 18:490. [PMID: 37430329 DOI: 10.1186/s13018-023-03982-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) and osteoarthritis (OA) are common diseases that are predicted to increase in prevalence, and DM is a risk factor for OA progression and has a negative impact on the outcome. However, the evidence remains unclear on how it affects patients' clinical results of total knee arthroplasty (TKA) under enhanced recovery after surgery (ERAS). METHODS A retrospective single-center study was conducted comparing diabetic and non-diabetic patients who underwent TKA in West China Hospital of Sichuan University between September 2016 to December 2017 under ERAS. Consecutive propensity score matching (PSM) was conducted by 1:1 (DM: non-DM) matching analysis with all baselines as covariates. The primary clinical results were the improvement of knee joint function, the incidence of postoperative complications, and the FJS-12 sensory results 5 years after the operation between DM and Non-DM groups. The secondary clinical results were the postoperative length of stay (LOS), postoperative blood test and total blood loss (TBL). RESULT After PSM, the final analysis included 84 diabetic patients and 84 non-diabetic patients. Diabetic patients were more likely to experience early postoperative complications (21.4% vs. 4.8%, P = 0.003), of which wound complications are the most significant (10.7% vs. 1.2%, P = 0.022). Diabetic patients experienced longer postoperative LOS with a significant increase in patients with LOS exceeding 3 days (66.7% vs. 50%, P = 0.028) and showed less postoperative range of motion (ROM) (106.43 ± 7.88 vs. 109.50 ± 6.33 degrees, P = 0. 011). Diabetic patients also reported lower Forgotten joint score (FJS-12) than non-diabetic patients (68.16 + 12.16 vs. 71.57 + 10.75, P = 0.020) in the 5-year follow-up and were less likely to achieve a forgotten knee joint (10.7% vs. 1.2%, P = 0.022). In additional, Compared with non-diabetics, diabetic patients showed lower hemoglobin (Hb) (P < 0.001) and hematocrit (HCT) (P < 0.001) and were more likely to suffer from hypertension before TKA (P < 0.001). CONCLUSION Diabetic patients show increased risk for postoperative complications, and have lower lower postoperative ROM and lower FJS-12 compared with non-diabetic patients after TKA under ERAS. More perioperative protocols are still needed to be investigated and optimized for diabetic patients.
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Affiliation(s)
- Shuai Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Haibo Si
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jiawen Xu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Liu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Bin Shen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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13
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Harmer JR, Wyles CC, Duong SQ, Morgan Iii RJ, Maradit-Kremers H, Abdel MP. Depression and anxiety are associated with an increased risk of infection, revision, and reoperation following total hip or knee arthroplasty. Bone Joint J 2023; 105-B:526-533. [PMID: 37121583 DOI: 10.1302/0301-620x.105b5.bjj-2022-1123.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation. Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded. Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report "much better" joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all). The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty.
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Affiliation(s)
- Joshua R Harmer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie Q Duong
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Robert J Morgan Iii
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hilal Maradit-Kremers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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14
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Nham FH, Patel I, Zalikha AK, El-Othmani MM. Epidemiology of primary and revision total knee arthroplasty: analysis of demographics, comorbidities and outcomes from the national inpatient sample. ARTHROPLASTY 2023; 5:18. [PMID: 37004093 PMCID: PMC10068145 DOI: 10.1186/s42836-023-00175-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 04/03/2023] Open
Abstract
INTRODUCTION Primary total knee arthroplasty (TKA) is a preferred treatment for end-stage knee osteoarthritis. In the setting of a failed TKA, revision total knee arthroplasty (rTKA) acts as a salvage procedure and carries a higher risk compared to primary TKA. Given increased interest in postoperative outcomes from these procedures, a thorough understanding of the demographics, comorbidities, and inpatient outcomes is warranted. This study aimed to report the epidemiological data of demographics, comorbidity profiles and outcomes of patients undergoing TKA and rTKA. METHODS A retrospective review of NIS registry discharge data from 2006 to 2015 third quarter was performed. This study included adults aged 40 and older who underwent TKA or rTKA. A total of 5,901,057 TKA patients and 465,968 rTKA patients were included in this study. Simple descriptive statistics were used to present variables on demographics, medical comorbidities, and postoperative complications. RESULTS A total of 5,901,057 TKA and 465,968 rTKA discharges were included in this study, with an average age of 66.30 and 66.56 years, and the major payor being Medicare, accounting for 55.34% and 59.88% of TKA and rTKA cases, respectively. Infection (24.62%) was the most frequent reason for rTKA, and was followed by mechanical complications (18.62%) and dislocation (7.67%). The most common medical comorbidities for both groups were hypertension, obesity, and diabetes. All types of inpatient complications were reported in 22.21% TKA and 28.78% of rTKA cases. Postoperative anemia was the most common complication in both groups (20.34% vs. 25.05%). CONCLUSIONS Our data demonstrated a 41.9% increase in patients receiving TKA and 28.8% increase in rTKA from the years 2006 to 2014. The data showed a 22.21% and a 28.78% "complication" rate with TKA and rTKA, with postoperative anemia being the most common complication. The top 3 medical comorbidities were hypertension, obesity, and diabetes for both groups and with increased focus on perioperative optimization, future analyses into preoperative medical optimization, and improved primary arthroplasty protocol may result in improved postoperative outcomes.
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Affiliation(s)
- Fong H Nham
- DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI, 48201, USA.
| | - Ishan Patel
- DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI, 48201, USA
| | - Abdul K Zalikha
- DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI, 48201, USA
| | - Mouhanad M El-Othmani
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 W 168Th Street, New York, NY, 10032, USA
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15
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Shichman I, Oakley CT, Konopka JA, Rozell JC, Schwarzkopf R, Lajam CM. Preoperatively elevated HbA1c levels can meaningfully improve following total joint arthroplasty. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04765-6. [PMID: 36703084 DOI: 10.1007/s00402-023-04765-6] [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: 09/06/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Prior literature has demonstrated that diabetic (DM) patients undergoing total joint arthroplasty (TJA) with elevated preoperative HbA1c scores have poorer clinical outcomes. However, no literature has reported the effect of undergoing TJA on laboratory markers of glycemic control. This study sought to evaluate effect of undergoing TJA on postoperative glycemic control and outcomes. METHODS This retrospective study reviewed all patients with DM who underwent primary, elective TJA at our high volume orthopedic institution. Included patients had at least one HbA1c value 3 months to 2 weeks pre-surgery and 3-6 months after surgery. Changes in HbA1c from before to after surgery were calculated. Change in HbA1c greater than 1.0% was considered clinically meaningful. Change in HbA1c was analyzed and stratified into subgroups. RESULTS In total, 770 primary TJA patients were included. Patients with preoperative HbA1c > 7% vs. ≤ 7% were significantly more likely to have clinically meaningful post-TJA decrease in HbA1c (24.5 vs. 2.9%, p < 0.001). Patients with preoperative HbA1c > 8 were significantly more likely to have decrease of > 2.0 compared to those with HbA1c < 8 (p < 0.001). Multivariate regression revealed that preop HbA1c > 7.0, former and current smokers, males, and African-Americans were significantly more likely to achieve clinically meaningful decrease in HbA1c. Additionally, postoperative increase in HbA1c > 1% was associated with significantly higher 90-day ED visits. DISCUSSION Patients with higher preoperative HbA1c were more likely to have clinically meaningful decreases in HbA1c postoperatively. A combination of preoperative medical optimization and improvements in mobility after TJA may play a role in these changes. Those with elevated HbA1c can have meaningful improvement in HbA1c after TJA.
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Affiliation(s)
- Ittai Shichman
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
- Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Christian T Oakley
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Jaclyn A Konopka
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Claudette M Lajam
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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16
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Scholten DJ, Gwam CU, Recker AJ, Plate JF, Waterman BR. Shared and unique risk factors for readmission exist following upper and lower extremity arthroplasty in the 30-day postoperative period. J Orthop Surg (Hong Kong) 2023; 31:10225536231155749. [PMID: 36815584 DOI: 10.1177/10225536231155749] [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] [Indexed: 02/24/2023] Open
Abstract
PURPOSE Joint arthroplasty has become increasingly more common in the United States, and it is important to examine the patient-based risk factors and surgical variables associated with hospital readmissions. The purpose of this study was to identify stratified rates and risk factors for readmission after upper extremity (shoulder, elbow, and wrist) and lower extremity (hip, knee, and ankle) arthroplasty. METHODS All patients undergoing upper and lower extremity arthroplasty from 2008-2018 were identified using the National Surgical Quality Improvement Program dataset. Patient demographics, medical comorbidities and surgical characteristics were examined utilizing uni- and multi-variate analysis for significant predictors of 30-days hospital readmission. RESULTS A total of 523,523 lower and 25,215 upper extremity arthroplasty patients were included in this study. A number of 22,183 (4.2%) lower and 1072 (4.4%) upper extremity arthroplasty patients were readmitted within 30 days of discharge. Significant risk factors for 30-days readmission after lower extremity arthroplasty included age, Body Mass Index (BMI), operative time, dependent functional status, American Society of Anesthesiologists (ASA) score ≥3, increased length of stay, and various medical comorbidities such as diabetes, tobacco dependency, and chronic obstructive pulmonary disease (COPD). An overweight BMI was associated with a lower odds of 30-days readmission when compared to a normal BMI for lower extremity arthroplasty. Analysis for upper extremity arthroplasty revealed similar findings of significant risk factors for 30-days hospital readmission, although diabetes mellitus was not found to be a significant risk factor. CONCLUSION Nearly one in 25 patients undergoing upper and lower extremity arthroplasty experiences hospital readmission within 30-days of index surgery. There are several modifiable risk factors for 30-days hospital readmission shared by both lower and upper extremity arthroplasty, including tobacco smoking, COPD, and hypertension. Optimization of these medical comorbidities may mitigate the risk short-term readmission following joint arthroplasty procedures and improve overall cost effectiveness of perioperative surgical care.
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Affiliation(s)
- Donald J Scholten
- Department of Orthopaedics, 528756Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Chukwuweike U Gwam
- Department of Orthopaedics, 528756Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Andrew J Recker
- School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian R Waterman
- Department of Orthopaedics, 528756Wake Forest Baptist Health, Winston-Salem, NC, USA
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Rosas S, Hegde V, Plate FJ, Dennis D, Jennings J, Bracey DN. Bacteremia in Patients Undergoing Debridement, Antibiotics, and Implant Retention Leads to Increased Reinfections and Costs. Arthroplast Today 2022; 16:259-263.e1. [PMID: 36092133 PMCID: PMC9458898 DOI: 10.1016/j.artd.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Debridement, antibiotics, and implant retention (DAIR) is a common treatment for acute prosthetic joint infection (PJI). The effects of concurrent bacteremia at the time of DAIR are poorly understood. This study sought to determine whether patients with bacteremia at the time of DAIR have higher reinfection rates. Material and methods A retrospective review of a national database was performed. Patients treated with DAIR (hip or knee arthroplasty) after a diagnosis of PJI were identified. DAIR patients who also had a diagnosis of bacteremia were matched to patients without bacteremia by comorbidities and Charlson Comorbidity Index score. The primary outcome was reinfection or continued infection at 90 days and 6, 12, and 24 months after DAIR. Ninety-day Medicare charges were compared between groups. Survival probabilities were used for survival comparisons. Results A total of 9945 patients underwent DAIR after a diagnosis of PJI. Seven hundred seven patients underwent DAIR with an associated diagnosis of bacteremia. Three hundred thirty-four DAIR patients with bacteremia were successfully matched to patients without bacteremia by age, gender, and comorbidities. DAIR survivorship was significantly worse in those with bacteremia at 90 days (51.5% vs 65.9%) and 6 (43.1% vs 60.5%), 12 (36.5% vs 56.0%), and 24 months (32.6% vs 53.3%) after DAIR. The 90-day costs of DAIR were significantly greater in PJI patients with bacteremia (mean: $14,722 standard deviation: $4086 vs mean: $8,052, standard deviation: $4,153, P < .01). Conclusions Patients undergoing DAIR with bacteremia are at an increased risk of reinfection or continued infection. Ninety-day costs are significantly increased (over 50%) in patients with bacteremia vs those without bacteremia.
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Levy N, McNally SA, Lobo DN. The need to improve opioid prescribing and data collection in patients undergoing orthopaedic surgery. Anaesthesia 2022; 77:854-857. [PMID: 35762197 DOI: 10.1111/anae.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - S A McNally
- Department of Trauma and Orthopaedics, East Sussex Healthcare NHS Trust, Eastbourne, Sussex, UK
- Honorary Clinical Professor, Brighton and Sussex Medical School, Brighton, UK
| | - D N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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19
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Length of Hospital Stay after Total Knee Arthroplasty: A Correlation Study on 1200 Patients. J Clin Med 2022; 11:jcm11082114. [PMID: 35456209 PMCID: PMC9029058 DOI: 10.3390/jcm11082114] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/29/2022] [Accepted: 04/09/2022] [Indexed: 02/04/2023] Open
Abstract
In countries with a high average population age, total knee arthroplasty is still carried out in an inpatient setting. The roadmap to performing major surgery on an outpatient basis passes through the understanding of those perioperative features that correlate with higher lengths of hospital stay (LOS). A retrospective database of 1200 patients was reviewed for retrieving preoperative and perioperative factors including anthropometric and demographic data, comorbidities, preoperative laboratory assessment, and surgical time. Considering the LOS as a discrete series, data were analyzed by means of logistic regression with multiple univariate and multivariate models. The results showed a median length of hospital stay of 3 (IQR 3, 4) days. According to multiple univariate analysis, arterial hypertension (p = 0.008), diabetes mellitus (p = 0.028), CCI score (p < 0.001), ASA score (p = 0.006), surgical time (p < 0.001) and intraoperative blood loss (p < 0.001) were significantly associated with the duration of hospital stay in days. Moreover, preoperative hemoglobin value was inversely correlated to the LOS (p = 0.008). Multivariate analysis showed a significant correlation between LOS and surgical time and intraoperative blood loss. Many factors influence the permanence of the inpatient and acting on those variables, by stabilizing comorbidities and optimizing laboratory values, may reduce the overall healthcare burden.
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20
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Sherman WF, Patel AH. Letter to the Editor: "Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?". Arthroplast Today 2021; 11:54-55. [PMID: 34466638 PMCID: PMC8387730 DOI: 10.1016/j.artd.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/25/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- William F. Sherman
- Corresponding author. 1430 Tulane Avenue #8632, New Orleans, LA 70112, USA. Tel.: +1-504-889-2663.
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21
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Zhang S, Chong M, Lau BPH, Ng YH, Wang X, Chua W. Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty? J Arthroplasty 2021; 36:2486-2491. [PMID: 33775468 DOI: 10.1016/j.arth.2021.02.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA. METHODS We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM). RESULTS Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866). CONCLUSION Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.
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Affiliation(s)
- Siyuan Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Chong
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Bernard Puang Huh Lau
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Yau Hong Ng
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Xinyu Wang
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Weiliang Chua
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
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22
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Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients. J Orthop Sports Phys Ther 2021; 51:269-280. [PMID: 33870736 DOI: 10.2519/jospt.2021.9515] [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] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA). DESIGN Prognosis systematic review. LITERATURE SEARCH We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019. STUDY SELECTION CRITERIA We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes. DATA SYNTHESIS For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis. RESULTS We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low. CONCLUSION Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.
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