Elective Total Joint Arthroplasty Research Articles

Low Socioeconomic Status Is Associated with Worse Patient-Reported Outcomes Following Total Joint Arthroplasty: A Systematic Review

BackgroundSocioeconomic status (SES)—an individual or group’s social standing or class, as measured by education, income, and occupation—has been associated with poor surgical outcomes in orthopaedics. Total knee (TKA) and total hip (THA) arthroplasties are the most commonly investigated orthopaedic surgeries regarding SES and patient-reported outcome measures (PROMs), yet the results are contradictory. The aim of this systematic review was to assess the impact of SES on PROMs following total joint arthroplasty (TJA). MethodsWe performed a literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines utilizing MEDLINE (Ovid), EMBASE (Ovid), and Cochrane Library from database inception (1971, 1974, and 1996, respectively) to August 2, 2023, to identify studies investigating SES and PROMs in adults undergoing primary elective TJA. Studies were included if they evaluated one of three SES variables (income, education, or employment status) and reported at least one-year scores using a validated PROM. There were two reviewers who independently screened studies and extracted data. ResultsThere were 16 studies included in this systematic review. A total of 55,875 arthroplasties, including 24,055 TKAs and 31,820 THAs, were analyzed. Of the studies, eight evaluated income, 15 evaluated education, and two evaluated employment status. The majority of studies investigating income found a statistically significant association between lower income and worse postoperative PROMs. There were ten studies, involving 90% of all patients from the included education studies, that found a statistically significant association between education and postoperative PROMs. There were two studies that found unemployed THA patients had lower improvements in PROMs compared to employed and retired patients. ConclusionOur systematic review found several significant associations between income, education, employment, and PROMs after TJA. Providers should pay special attention to lower-income, less educated, and unemployed patients. These patients may benefit from targeted interventions to achieve substantial clinical benefit after TJA.

Determining Appropriateness of Total Joint Arthroplasty for Hip and Knee Osteoarthritis: A Patient-Centred Conceptual Model.

Total joint arthroplasty (TJA) for osteoarthritis is one of several treatment options with benefits and harms that patients value differently. However, the process for determining TJA appropriateness does not sufficiently acknowledge patient perspectives. The aim of this paper is to propose an evidence-informed patient-centred conceptual model for elective TJA appropriateness for hip and knee osteoarthritis. Our interprofessional team developed a conceptual model for determining the appropriateness of adults considering elective TJA. The model was informed by a review of the evidence, a qualitative study we conducted with adults who underwent TJA for osteoarthritis to determine barriers and facilitators to the use of appropriateness criteria, and the research and clinical experience of team members. Appropriateness is providing health services (e.g., TJA) with net benefits to the right patient at the right time. The proposed Patient-centred Elective TJA Appropriateness Conceptual Model involves three key steps. First, assess adults with osteoarthritis to determine eligibility for TJA. Second, acknowledge the patient's informed preferences including their expectations and goals. Third, explore and support their mental and physical readiness for TJA. Given that osteoarthritis is a chronic condition, these steps can be revisited over time with patients. Our proposed conceptual model reconceptualises the appropriateness of TJA to be more patient-centred. Hence, this approach has the potential to be a more inclusive approach and ensure patients undergoing TJA are eligible, ready to proceed, and achieve what matters most to them. Future research is needed to test and validate the model.

Identification and optimisation of perioperative factors for patients with von Willebrand disease undergoing elective total hip and knee arthroplasty.

Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

Smoking cessation prior to elective total joint arthroplasty results in sustained abstinence postoperatively.

Tobacco use is a well-documented modifiable risk factor for perioperative complications. To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty (TJA) procedure. A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery. Eligible patients were contacted via phone survey to understand their tobacco use pattern, and patient reported outcomes. A total of 37 TJA patients participated. Our cohort was on average 61-years-old, 60% (n = 22) women, with an average body mass index of 30 kg/m2. The average follow-up time was 2.9 ± 1.9 years. A total of 73.0% (n = 27) of patients endorsed complete abstinence from tobacco use prior to surgery. Various cessation methods were used perioperatively including prescription therapy (13.5%), over the counter nicotine replacement (18.9%), cessation programs (5.4%). At final follow up, 43.2% (n = 16) of prior tobacco smokers reported complete abstinence. Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System (PROMIS)-10 mental health scores (49 vs 58; P = 0.01), and hip dysfunction and osteoarthritis outcome score for joint replacement (HOOS. JR) scores (63 vs 82; P = 0.02). No patients in this cohort had a prosthetic joint infection or required revision surgery. We report a tobacco cessation rate of 43.2% in patients undergoing elective TJA nearly 3 years postoperatively. Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS. JR scores. The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.

Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review.

Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management. This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored. A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests. Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence. Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients.

Serum Fructosamine as an Indicator of Perioperative Complications in Patients Undergoing Foot and Ankle Surgery.

Patients with poor glycemic control are at increased risk of postoperative complications. Hemoglobin A1c (HbA1c) has traditionally been used to assess preoperative glycemic control, but with limitations. More recently, fructosamine has been tested preoperatively in patients undergoing elective total joint arthroplasty. This study aims to assess whether preoperative serum fructosamine can be used to avoid adverse outcomes in patients undergoing foot and ankle surgery. This was a retrospective chart review of all patients who underwent foot and ankle surgeries at 2 level 1 trauma centers from January 2020 to December 2021. Of those, 305 patients were tested for HbA1c and fructosamine levels preoperatively. Adverse outcomes were assessed over 30 and 90 days. Outcomes of interest were surgical site infection, wound dehiscence, unplanned return to the operating room, unplanned readmission, and death. Data were analyzed using independent 2-sample t tests. A mixed effects model was used for multivariate analysis. P values less than .05 were considered statistically significant. Preoperative serum fructosamine was significantly higher (P = .029) in those with complications within 90 days compared to those without. The mean preoperative fructosamine level was 269.2 µmol/L (SD = 58.85) in those who did have a complication vs 247.2 µmol/L (SD = 53.95) in those who did not. Clinically significant fructosamine threshold was determined using 2 different methods. Fructosamine was found to be non-inferior to HbA1c in accurately predicting postoperative complications. Fructosamine is a serum marker that reflects nearer term glycemic control than HbA1c. Elevation in preoperative fructosamine is associated with increased perioperative complications after foot and ankle surgery within 90 days. Preoperative fructosamine may be used in patient optimization and risk stratification when determining candidacy and timing for elective foot and ankle surgeries. Level III, retrospective cohort study.

Perioperative Dexamethasone is Associated With a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients

BackgroundDexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). MethodsPatients who have a history of VTE who underwent primary elective TJA from 2015 to 2021 were identified using a commercial health care database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(−)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. ResultsOverall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < .001) and had a significantly shorter length of stay compared to the DEX(−) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < .001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < .001) and DVT (2.37 versus 3.01%, P < .001) compared to DEX(−) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio: 0.78, 95% confidence interval: 0.66 to 0.93, P = .006) and DVT (adjusted odds ratio: 0.84, 95% confidence interval: 0.74 to 0.95, P = .006) compared to DEX(−) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(−) patients (P > .05). ConclusionsThe administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA. Level of EvidenceLevel III.

INCIDENTAL FINDINGS AND CLINICAL SIGNIFICANCE OF PREOPERATIVE CT IMAGING FOR THE PLANNING OF ROBOTIC ARTHROPLASTY

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning.The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty.All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation.A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%)Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BackgroundAfrican Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. MethodsPatient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher’s exact tests were used to compare categorical variables, while 2-tailed Student’s Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. ResultsThe liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). ConclusionsThe HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Opiate prescription after hip and knee arthroplasty: a retrospective cohort study.

Excessive opiate analgesia in relation to orthopaedic surgery is associated with morbidity and mortality. Pre-operative use of opiates is associated with higher post-operative use. There is little information about opiate prescribing practices in relation to elective total joint arthroplasty (TJA) in New Zealand rural centres. The aims of this study were to describe opiate use before, immediately after and 1 year after TJA, and to compare prescribing practices with local guidelines. A retrospective cohort study of elective primary hip and knee arthroplasties was conducted between January 2018 and April 2019. Opiate use was evaluated from clinical records and from electronic prescribing records and described in morphine milligram equivalents (MME) with a particular focus on pre-operative and post-operative periods, and use after 1 year. In the study period, 199 patients underwent 203 joint arthroplasties. Of these, data from 157 patients were analysed. Patient data were not analysed because of unavailable files (N=20), non-elective procedures (N=11), bilateral arthroplasties (N=4), deaths (N=4) and incomplete information (N=3). Pre-operative opiates were used by 92 (59%) patients, of whom 70 (76%) were not using opiates after 1 year. There were 126 (80%) patients who were discharged with opiate prescriptions and the vast majority, 121 (96%), did not receive discharge prescriptions that conformed to local guidelines. Despite undergoing joint arthroplasty, about one quarter of patients who had been prescribed opiates before the operation were still receiving opiates after 1 year. There was poor compliance with local guidelines.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California

BackgroundInpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic. MethodsAdult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05. ResultsIn New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA. ConclusionsThis present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly. Level of EvidenceTherapeutic Level IV, Retrospective Cohort Study.

Maintenance of Surgical Optimization in Total Joint Arthroplasty Patients

BackgroundThere are increased efforts to maximize medical optimization to improve the outcomes of total joint arthroplasty (TJA). However, there is a paucity of literature demonstrating that optimized parameters are maintained throughout the perioperative period. MethodsA retrospective review of 877 elective TJA patients from 2015 to 2019 was conducted. Patients who underwent medical optimization for body mass index (BMI), hemoglobin A1c (HbA1c), hemoglobin, albumin, and smoking status were reviewed at the initial visit, preoperatively, time of surgery, and one year postoperatively. For each of these variables at each time point, patients were stratified into 3 optimization groups. Analyses were performed to identify mean time to optimization, loss of optimization, and maintenance of optimization. ResultsPatients considered not optimized due to specific parameters at the initial visit were as follows: BMI (19%), HbA1c (13.5%), hemoglobin (16%), albumin (19%), and smoking status (9.5%). The mean time to optimization was 187.7 days [longest being BMI (220.1 days), and the shortest being HbA1c (60.9 days) (P = .0003)]. Patients who had intermediate optimization of BMI at the preoperative visit were at higher risk [odds ratio: 2.1 (0.97 to 4.6)] of worsening BMI by time of surgery (P < .0001). Between the preoperative and surgery time points, over 93.5% of patients maintained or improved optimization. ConclusionsSurgeon led medical optimization efforts alongside a TJA program provide maintenance of, or improvement in optimization in more than half of TJA patients up to one year postoperatively. Patients who had a BMI between 40 and 45 at the preoperative visit are at significant risk of increasing their BMI by the day of surgery.

Prevalence of Methicillin Resistant Staphylococcus aureus Colonisation in Patients undergoing Total Joint Arthroplasty: A Retrospective Observational Study

Introduction: Methicillin Resistant Staphylococcus aureus (MRSA) presents a significant, yet preventable, complication in Total Joint Arthroplasties (TJAs). Surgical Site Infections (SSIs) of prosthetic joints resulting from MRSA lead to substantial patient morbidity, mortality, and impose a significant burden on healthcare budgets. One method to mitigate these risks is to screen for MRSA colonisation prior to elective surgeries. The prevalence of MRSA colonisation in nasal mucosa ranges from 0.18-7.2% in different patient populations, with a nosocomial prevalence of 1.7%. Aim: To determine the prevalence of MRSA colonisation in all patients undergoing elective TJA, including Total Hip Replacement (THR) or Total Knee Replacement (TKR). Materials and Methods: A retrospective observational study was conducted on a total of 407 patients scheduled for elective TJAs. Data from 407 patients who underwent elective TJA between January 2020 and December 2022 (a period of three years) were selected for the study. Data compilation and analysis of the study subjects were performed retrospectively until March 2023 at the Sanjay Gandhi Institute of Trauma and Orthopaedics, a tertiary care Orthopaedic centre in Bengaluru, Karnataka, India. The study subjects were screened for MRSA colonisation through nasal swab culture and sensitivity. Patients with positive MRSA culture results were treated with decolonisation therapy, which involved the local application of 2% mupirocin and chlorhexidine body wash for five days. Descriptive data analytics were employed in the study, and tables were generated using Microsoft Word 2010 and Microsoft Excel 2010 (Microsoft Corp, Redmond, WA, USA). Results: The prevalence rates of MRSA nasal colonisation were n1=8 (8.42%), n2=2 (2%), and n3=16 (7.55%) for the years 2020 (n1), 2021 (n2), and 2022 (n3), respectively, at the centre. The period prevalence rate of MRSA colonisation in the nasal mucosa over three years was N=26 (6.4%). Conclusion: The present study revealed a high period prevalence of MRSA colonisation (6.4%) in patients undergoing TJAs. Therefore, all elective TJAs should undergo MRSA screening and decolonisation using 2% intranasal mupirocin and daily chlorhexidine body wash for five days as a successful treatment modality for all patients with MRSA-positive nasal colonisation. This approach helps prevent postoperative SSIs caused by MRSA.

Impact of preoperative frailty on choice of anesthesia modality and outcomes in elderly total joint replacement patients

This study investigated the correlation between the degree of frailty and postoperative adverse outcomes after total joint arthroplasty (TJA) in patients undergoing TJA who received general anesthesia (GA) or intraspinal anesthesia (IA). The cohort comprised 660 elderly patients who underwent TJA and were assessed using the Fatigue, Resistance, Ambulation, Illness and Loss of Weight (FRAIL) scale. A total of 660 patients aged 65 years or older who underwent elective total joint arthroplasty were included in the analysis. Of them, 182 (27.58%) were identified as frail. GA was performed in 252 patients and IA in 408 patients. The type of anesthesia did not significantly affect outcomes across the Healthy, Pre-frailty and Frailty groups (p &gt; 0.05). During the 1-year follow-up period, 78 deaths occurred: 3 in the Healthy group, 16 in the Pre-frailty group, and 59 in the Frailty group, revealing significant differences in mortality rates among these groups (p &lt; 0.05). Multivariate logistic regression analysis indicated that frailty significantly increased the risk of 1-year postoperative mortality following total joint arthroplasty in this elderly cohort (p &lt; 0.05). Specifically, the Frailty group exhibited a 2.674-fold higher risk of 1-year postoperative death compared to the Healthy group. Further analysis within the frail elderly population demonstrated that GA was a significant predictor of increased 1-year postoperative mortality risk (p &lt; 0.05), with frail patients undergoing GA experiencing a 2.958-fold higher risk of death within one year post-operation compared to those receiving IA. In conclusion, the results support prioritizing IA in frail elderly patients to minimize the adverse effects of GA on long-term mortality risk.

AZU1: a new promising marker for infection in orthopedic and trauma patients?

Early and reliable detection of infection is vital for successful treatment. Serum markers such as C-reactive protein (CRP) and procalcitonin (PCT) are known to increase with a time lag. Azurocidin 1 (AZU1) has emerged as a promising marker for septic patients, but its diagnostic value in orthopedic and trauma patients remains unexplored. Between July 2020 and August 2023, all patients necessitating inpatient treatment for periprosthetic joint infection (PJI), peri-implant infection (II), soft tissue infection, chronic osteomyelitis, septic arthrodesis, bone non-union with and without infection were enrolled. Patients undergoing elective total joint arthroplasty (TJA) served as the control group. Blood samples were collected and analyzed for CRP, white blood cell count (WBC), PCT, and AZU1. Based on the inclusion and exclusion criteria 222 patients were included in the study (trauma = 38, soft tissue infection = 75, TJA = 33, PJI/II = 39, others = 37). While sensitivity and specificity were comparably high for AZU1 (0.734/0.833), CRP and PCT had higher specificity (0.542/1 and 0.431/1, respectively), and WBC a slightly higher sensitivity (0.814/0.455) for septic conditions. Taken together, the area under the curve (AUC) showed the highest accuracy for AZU1 (0.790), followed by CRP (0.776), WBC (0.641), and PCT (0.656). The Youden-Index was 0.57 for AZU1, 0.54 for CRP, 0.27 for WBC, and 0.43 for PCT. Elevated AZU1 levels effectively distinguished patients with a healthy condition from those suffering from infection. However, there is evidence suggesting that trauma may influence the release of AZU1. Additional research is needed to validate the diagnostic value of this new biomarker and further explore its potential clinical applications.

Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty.

Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty.

Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not. Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders. The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001). TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Impact of Postoperative COVID-19 Infection Status on Outcomes in Elective Primary Total Joint Arthroplasty

BackgroundAlthough Coronavirus disease 2019 (COVID-19) infection causes major morbidity and mortality, it is unclear what the impact of postoperative COVID-19 infection is on 30-day outcomes after total joint arthroplasty (TJA). MethodsThere were 2,340 patients who underwent TJA in 2021, identified using the National Surgical Quality Improvement Program database, with 925 total hip arthroplasty (THA) patients (39.5%) and 1,415 total knee arthroplasty (TKA) patients (60.5%), overall. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for postoperative COVID-19–positive and COVID-19–negative patients who underwent TKA or THA. ResultsPostoperative COVID-19–positive THA patients were found to have a significantly increased risk of pneumonia (odds ratio [OR] 42.57), sepsis (OR 12.77), readmission (OR 12.06), non-home discharge (OR 3.78), and longer length of stay (hazard ratio 1.62). Postoperative COVID-19–positive TKA patients had an increased risk of 30-day mortality (OR 14.17), superficial infection (OR 3.17), pneumonia (OR 34.68), unplanned intubation (OR 18.31), ventilator use for more than 48 hours (OR 18.31), pulmonary embolism (OR 11.98), urinary tract infection (OR 5.16), myocardial infarction (OR 16.02), deep vein thrombosis (OR 4.69), non-home discharge (OR 1.79), reoperation (OR 3.17), readmission (OR 9.61), and longer length of stay (hazard ratio 1.49). ConclusionsPatients who contracted COVID-19 within 30 days after TJA were at increased risk of mortalities, medical complications, readmissions, reoperations, and non-home discharges. It is important for orthopedic surgeons to understand these adverse outcomes to better counsel patients and mitigate these risks, particularly in higher risk populations.

The Role of a Registered Dietitian Nutritionist in Improving Weight Loss Prior to Elective Total Joint Arthroplasty in Overweight or Obese Adults Among Participants in MODIFY, a Pre-surgical Optimization Program

The Role of a Registered Dietitian Nutritionist in Improving Weight Loss Prior to Elective Total Joint Arthroplasty in Overweight or Obese Adults Among Participants in MODIFY, a Pre-surgical Optimization Program

Staphylococcus aureus colonization and periprosthetic joint infection in patients undergoing elective total joint arthroplasty: a narrative review.

Peri-prosthetic joint infections (PJIs) following total joint arthroplasty (TJA) are associated with higher treatment costs, longer hospital admissions and increased morbidity and mortality. Colonization with Staphylococcus aureus is an independent and modifiable risk factor for PJIs and carriers of S. aureus are ten times more likely than non-carriers for post-operative infections. Screening and targeted decolonization, vs universal decolonization without screening, remains a controversial topic. We recommend a tailored approach, based on local epidemiological patterns, resource availability and logistical capacity. Universal decolonization is associated with lower rates of SSI and may reduce treatment costs.