Joint Arthroplasty Patients Research Articles

Are Patients’ Relationships to their Primary Contacts Associated with Postoperative Outcomes after Total Joint Arthroplasty?

BACKGROUNDSocial determinants strongly influence overall health, including recovery after total joint arthroplasty (TJA). The modern electronic health record (EHR) includes a list of individuals identified by patients as their primary contacts. We aimed to assess whether the relationship between patients and their documented primary contacts was associated with outcomes after TJA. METHODSWe retrospectively reviewed primary, elective total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) at a single institution from June 2011 to December 2022 and stratified patients into two groups: Family (F) [familial relationships to include spouse, first/second degree relative] or Non-Family (NF) [non-familial relationships such as friend, neighbor] based on patient relationship to their primary emergency contact. Baseline characteristics and postoperative outcomes were compared. Binary logistic regression was utilized to assess variables associated with all-cause revision. In total, 17,520 THAs were included: 16,123 (92.0%) in the F group and 1,397 (8.0%) in the NF group. Additionally, 20,397 TKAs were included: 18,819 (92.3%) in the F group and 1,578 (7.7%) in the NF group. RESULTSFor both THA and TKA patients, having a NF primary contact was independently associated with a higher risk of all-cause revision at the latest follow-up (OR [odds ratio]: 1.48 [95% CI (confidence interval): 1.05 to 2.08], P = 0.025) and (OR: 1.62 [95% CI: 1.10 to 2.38], P = 0.014), respectively. In both THA and TKA, the F group had shorter lengths of stay (P < 0.001) and was more likely to be discharged home (P < 0.001) compared to the NF group. CONCLUSIONTotal joint arthroplasty patients who have a familial primary contact demonstrate better postoperative outcomes compared to those who do not have a familial contact. Awareness of social support and additional postoperative support for patients who have NF primary contacts may be warranted following TJA.

Complete Blood Cell Count-Based Ratios Identify Total Joint Arthroplasty Patients Likely to Benefit from Perioperative Dexamethasone

Background: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization. Methods: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles. Results: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of &gt;1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p &lt; 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR &lt;1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of &lt;0.24 (the lowest quartile) (p = 0.039). Conclusions: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid Is Safe in Arthroplasty Patients Who Have a History of Venous Thromboembolism: An Analysis Accounting for Surgeon Selection Bias

BackgroundRetrospective data supporting the use of tranexamic acid (TXA) among high-risk total joint arthroplasty (TJA) patients are limited by surgeon selection bias. This study sought to evaluate the thromboembolic risk associated with TXA administration among elective arthroplasty patients who have history of venous thromboembolism while accounting for surgeon selection. MethodsA healthcare database was retrospectively queried from 2015 to 2021 to identify all patients who had a history of deep vein thrombosis or pulmonary embolism who underwent elective TJA. Patients were categorized into two cohorts: (1) patients treated by a surgeon who used TXA in 0 to 30% of cases; and (2) patients treated by a surgeon who used TXA in 90 to 100% of cases. Patients were assessed based on the surgeon who treated them rather than their exposure to TXA. Demographics, comorbidities, and the incidence of 90-day postoperative complications were compared between the two groups. Multivariable and instrumental variable analysis using surgeon as an instrument were conducted to account for confounding factors. ResultsIn total, 70,759 high-risk elective TJA patients were identified, of which 7,190 (10.2%) were performed by surgeons in the infrequent-TXA cohort and 9,478 (13.4%) were performed by surgeons in the frequent-TXA cohort. On instrumental variable analysis, patients treated by surgeons in the frequent-TXA cohort had a lower risk of aggregate bleeding complications (instrumental variable odds ratio 0.94, 95% confidence interval: 0.89 to 0.98, P = 0.005), including transfusion (instrumental variable odds ratio 0.60, 95% confidence interval: 0.54 to 0.66, P < 0.001). However, no significant differences were observed in postoperative deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction between the two cohorts (P > 0.05). ConclusionsAfter accounting for surgeon selection, TXA administration was associated with a significant reduction in early postoperative bleeding complications with no observed increase in thromboembolic risk. Given the favorable safety profile, surgeons should consider TXA among high-risk arthroplasty patients.

Safety and Efficacy of Aspirin Compared to Enoxaparin Following Total Hip and Total Knee Arthroplasty Among Patients Who Have a History of Venous Thromboembolic Disease

BackgroundDespite the broad utilization of aspirin (ASA) as a venous thromboembolism (VTE) chemoprophylactic agent following total knee arthroplasty (TKA) and total hip arthroplasty (THA), few studies have evaluated its safety and efficacy in patients who had a history of VTE. This study sought to evaluate the safety and efficacy of ASA relative to enoxaparin in high-risk total joint arthroplasty patients. MethodsAn all-payer claims database was queried for primary, elective THA, and TKA patients from January 2015 to December 2021. Patients who had a history of VTE were divided based on receipt of either ASA or enoxaparin as VTE prophylaxis. In a 1:1 ratio, 1,429 THA and 2,864 TKA high-risk ASA patients were matched to high-risk enoxaparin patients on age, sex, race, and presence of pertinent comorbidities. Multivariable regression analyses accounted for potential confounders. ResultsAfter multivariable analyses, similar risk of pulmonary embolism (THA: adjusted odds ratio [aOR]: 0.85, 95% confidence interval [CI]: 0.26 to 2.76; TKA: aOR: 0.71, 95% CI: 0.38 to 1.32) and deep vein thrombosis (DVT) (THA: aOR: 1.12, 95% CI: 0.53 to 2.36) was observed in the ASA cohorts relative to the enoxaparin cohorts. TKA patients in the ASA cohort had a lower risk of DVT than those in the enoxaparin cohort (aOR: 0.57, 95% CI: 0.33 to 0.96). THA ASA patients demonstrated a reduced risk of stroke (aOR: 0.03, 95% CI: 0.00 to 0.73), while TKA ASA patients had a lower risk of acute blood loss anemia (aOR: 0.77, 95% CI: 0.66 to 0.88). ConclusionsHigh-risk patients who received ASA demonstrated similar risk of pulmonary embolism and DVT, but decreased risk of bleeding-related and medical complications compared to patients who received enoxaparin. The utilization of ASA in high-risk patients was not associated with an increased risk of adverse outcomes.

Periprosthetic Joint Infection in Patients With Inflammatory Arthritis: Optimal Tests to Differentiate From Flares.

Diagnosis of periprosthetic joint infection (PJI) in patients with inflammatory arthritis (IA) is challenging, as features of IA flares can mimic infection. We aimed to cross-sectionally determine if the optimal tests to diagnose PJI in osteoarthritis were present in patients with IA flares. We enrolled patients from October 2020 to July 2022 in 3 groups: (a) PJI-total joint arthroplasty patients undergoing revision for infection, (b) IA Flare-IA patients with a flaring native joint, and (c) IA Aseptic-total joint arthroplasty patients with IA undergoing aseptic arthroplasty revision. We compared blood and synovial fluid markers between the cohorts using Kruskal-Wallis and Fisher exact tests to assess marker sensitivity and specificity. Of 52 cases overall, 40% had rheumatoid arthritis, 20% psoriatic arthritis, and 11% osteoarthritis (in PJI group). PJI cases had higher C-reactive protein (CRP) and synovial fluid polymorphonuclear neutrophil percentage (%PMN). Alpha-defensin tested positive in 93% of PJI cases, 20% of IA Flares, and 6% of IA Aseptic (p < 0.01). Synovial white blood cell count >3000/μL and positive alpha-defensin were highly sensitive (100%) in diagnosing infection; however, specificity was 50% for white blood cell counts and 79% for alpha-defensin. PJI diagnosis was nearly 5 times more likely with positive alpha-defensin and almost 6 times more likely with %PMNs >80. Blood markers interleukin-6, procalcitonin, and d-dimer were neither sensitive nor specific, whereas erythrocyte sedimentation rate and CRP showed 80% sensitivity, but 47% and 58% respective specificities. Although synovial %PMNs, CRP, and alpha-defensin are sensitive tests for diagnosing PJI, they are less specific and may be positive in IA flares.

Matrix-bound nanovesicles alleviate particulate-induced periprosthetic osteolysis.

Aseptic loosening of orthopedic implants is an inflammatory disease characterized by immune cell activation, chronic inflammation, and destruction of periprosthetic bone, and is one of the leading reasons for prosthetic failure, affecting 12% of total joint arthroplasty patients. Matrix-bound nanovesicles (MBVs) are a subclass of extracellular vesicle recently shown to mitigate inflammation in preclinical models of rheumatoid arthritis and influenza-mediated "cytokine storm." The molecular mechanism of these anti-inflammatory properties is only partially understood. The objective of the present study was to investigate the effects of MBV on RANKL-induced osteoclast formation in vitro and particulate-induced osteolysis in vivo. Results showed that MBV attenuated osteoclast differentiation and activity by suppressing the NF-κB signaling pathway and downstream NFATc1, DC-STAMP, c-Src, and cathepsin K expression. In vivo, local administration of MBV attenuated ultrahigh molecular weight polyethylene particle-induced osteolysis, bone reconstruction, and periosteal inflammation. The results suggest that MBV may be a therapeutic option for preventing periprosthetic loosening.

An Evaluation of the Safety of Half-Dose Direct Oral Anticoagulants Following Total Joint Arthroplasty: A Pilot Study.

Background Total joint arthroplasty (TJA) patients on preoperative anticoagulation therapy present a challenge for adult reconstructionsurgeons. The goal in managing such patients is to limit bleeding complications associated with administering the medications while preventing medical complications from withholding them. At our institution, we began a protocol in 2017 that utilizes a half-dose direct oral anticoagulant (DOAC) regimen for one week followed by resuming of the full-dose regimen in select patients who underwent TJA. This study investigated the 90-day safety profile associated with this protocol compared to previous literature. Methodology A retrospective review of 898 patients from a single institution was conducted including allpatients receiving a half-dose DOAC protocol for one week followed by resuming of the full-dose regimen after total knee and total hip arthroplasty between 2017 and 2022. Data were collected on patient demographics, type of surgery, and DOAC dosage. Ninety-day complications were collected and separated into reduced dose complications of DOAC (such as cerebrovascular accidents (CVAs) or venothrombotic events (VTEe)) and DOAC therapy-related complications (including wound and bleeding complications). Results In the total hip arthroplasty (THA) subgroup (n = 396, 44.10%), there were four major VTE occurrences, aligning with therange seen in historical protocols. Deep vein thrombosis (DVT) and pulmonary embolism (PE) incidents were three and one, respectively, both within the historical range. In the total knee arthroplasty (TKA) subgroup of 502 (55.90%) patients, there were seven major VTE events, with five DVTs and two PEs, also aligning with historical ranges. Medical complications in the THA group included no CVA events and one myocardial infarction, with the latter slightly higher than the historical range. In the TKA group, there were two medical complications, both being CVAs. Regarding bleeding complications, THA patients showed four major bleeding incidents, two blood transfusions, and two hemorrhages, with these numbers comparable to or lower than historical ranges. There were seven minor bleeding events. For TKA, there were two major bleeding events, two blood transfusions, no hemorrhages, and five minor bleeding events. Wound complications in THA included five surgery-related complications, two cases of wound dehiscence, and three infections. TKA patients experienced 17 surgery-related complications, six cases of wound dehiscence, and 11 infections. Conclusions This study suggests that the half-dose DOAC protocol in patients undergoing TJA is non-inferior to historical full-dose DOACprotocolswarranting further investigation to generalize across broader populations.

Do Racial Disparities Impact Healthcare Costs and Resource Utilization after Total Joint Replacements?

Background Racial disparities currently exist in healthcare and can have a significant impact on patient outcomes and access to quality care. Previous studies have indicated that black patients are more likely to experience delays in treatment and increased surgical complications. Hispanic patients have more comorbidities and increased complications when undergoing orthopaedic surgeries. The purpose of this study was to evaluate the impact of racial disparities on postoperative complications and readmission rates following Total Joint Arthroplasty (TJA). Methods The largest single healthcare network database was queried to identify total joint arthroplasty patients treated in a single division between 2017 and 2021. Patient demographics including age, race, gender, and comorbidities were collected. Logistic regression and odds ratio point estimate analyses were utilized to assess for associations between race (defined as Whites, Blacks, Hispanics, Asians, and Others) and postoperative medical complications and surgical complications, which were collected for all patients. Patient outcomes included length of stay, hospital readmission status at 30 and 90 days postoperative, and emergency room (ER) visits up to 90 days. Results A total of 16,940 patients were included in this analysis consisting of 62% female, a mean age of 71 years and mean BMI of 29.4 kg/m2 . Racial demographics consisted of 61.6% White, 12.3% Black, 24.1% Hispanic, 0.8% Asian, and 1.2% Other. Race was not significantly associated with increased readmissions at 30 days (p=0.2215) and hispanic patients were 14% less likely to be readmitted within 90 days (p = 0.0208) but were not found to have differences in ER visits when compared to White patients. Black and Asian patients were not significantly more likely to visit the ER within 90 days or to be readmitted to the hospital within 90 days when compared to White patients. Race was not significantly associated with postoperative medical complications or surgical complications. Conclusions This study found a higher readmission rate of up to 20% for total joint arthroplasty patients within 90 days of follow-up. Although race did not appear to be a significant determinant of additional ER visits or readmissions, there was some variation seen amongst Hispanic patients undergoing TJR with a lower likelihood of readmission at 60 and 90 days postoperative.

Post-surgical Dental Precautions/Prophylaxis in Pediatric Patients: Results of a 2023 Survey of the Membership of the Pediatric Orthopaedic Society of North America

IntroductionGuidelines regarding postsurgical dental care have been common in adult total joint arthroplasty patients despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in postoperative pediatric orthopaedic patients without any published evidence to guide clinicians. MethodsA survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of postsurgical guidelines regarding dental care (procedures and prophylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. ResultsOne hundred seventy-three POSNA Members opened the link to the survey. One hundred sixty-three respondents self-identified as Active, for a response rate of 19.8%. One hundred fifty-seven (96.3%) reported direct involvement in surgical and postsurgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a postoperative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. ConclusionsThese results demonstrate that many of the active Members of POSNA utilize postsurgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients and no literature regarding use of such guidelines in pediatric orthopaedic patients. Key Concepts(1)There is limited and contradictory evidence that postsurgical dental guidelines are indicated in adult orthopaedic patients.(2)There is no published evidence supporting postsurgical dental guidelines in pediatric orthopaedic patients.(3)Almost 40% of active Pediatric Orthopaedic Society of North America Members responding to a survey appear to utilize postsurgical dental care guidelines in pediatric patients, particularly after spinal procedures utilizing implants. Level of EvidenceLevel V

Blood metal concentrations and cardiac structure and function in total joint arthroplasty patients.

There is concern regarding potential long-term cardiotoxicity with systemic distribution of metals in total joint arthroplasty (TJA) patients. To determine the association of commonly used implant metals with echocardiographic measures in TJA patients. The study comprised 110 TJA patients who had a recent history of high chromium, cobalt or titanium concentrations. Patients underwent two-dimensional, three-dimensional, Doppler and speckle-strain transthoracic echocardiography and a blood draw to measure metal concentrations. Age and sex-adjusted linear and logistic regression models were used to examine the association of metal concentrations (exposure) with echocardiographic measures (outcome). Higher cobalt concentrations were associated with increased left ventricular end-diastolic volume (estimate 5.09; 95%CI: 0.02-10.17) as well as left atrial and right ventricular dilation, particularly in men but no changes in cardiac function. Higher titanium concentrations were associated with a reduction in left ventricle global longitudinal strain (estimate 0.38; 95%CI: 0.70 to 0.06) and cardiac index (estimate 0.08; 95%CI, -0.15 to -0.01). Elevated cobalt and titanium concentrations may be associated with structural and functional cardiac changes in some patients. Longitudinal studies are warranted to better understand the systemic effects of metals in TJA patients.

Clinical outcomes of total joint arthroplasty in patients with bowel ostomies.

The influence of prior colostomy or ileostomy on patients undergoing joint arthroplasty remains poorly understood. Our study aimed to assess whether patients with an ostomy undergoing hip and knee arthroplasties have worse postoperative outcomes and increased rates of revisions. A single-center, retrospective review of patients with a history of bowel ostomy who underwent a primary total hip arthroplasty (THA), hemiarthroplasty (HA), and total knee arthroplasty (TKA) from 2012 to 2021. A total of 24 THAs, 11 HAs, and 25 TKAs in patients with open small or large bowel stoma were identified. A ten-to-one propensity score match was utilized to establish cohorts with comparable demographics but no prior ostomy procedure. Patients with stomas undergoing elective THA showed greater 90-day ED visits (20.0 vs. 5.0%, P = 0.009), 90-day all-cause readmissions (20.0 vs. 5.0%, P = 0.009), 90-day non-orthopedic readmissions (10.0 vs. 0.5%, P < 0.001), 90-day readmissions for infection (5.0 vs. 0.5%, P = 0.043), all-cause revisions (15.0 vs. 0.5%, P < 0.001), revisions for PJI (5.0 vs. 0%, P = 0.043), and revisions for peri-prosthetic fracture (10.0 vs. 0%, P < 0.001). Patients with stomas undergoing non-elective hip arthroplasties exhibited a longer mean LOS (12.1 vs. 7.0 days, P < 0.001) and increased 90-day all-cause readmissions (40.0 vs. 17.3%, P = 0.034), 90-day orthopedic readmissions (26.7 vs. 6.0%, P = 0.005), all-cause revisions (13.3 vs. 2.0%, P = 0.015), revisions for peri-prosthetic fracture (6.7 vs. 0%, P = 0.002), and revisions for aseptic loosening (6.7 vs. 0%, P = 0.002). There were no significant differences in readmission or revision rates between ostomy patients undergoing TKA and a matched control group. Patients undergoing hip arthroplasties with an open stoma are at an increased risk of hospital encounters and revisions, whereas TKA patients with stomas are not at increased risk of complications. These findings emphasize the importance of recognizing and addressing the unique challenges associated with this patient population.

Body Mass Index is Not an Appropriate Proxy for the Condition of Peri-Incisional Adiposity in Primary Total Joint Arthroplasty Patients

BackgroundThe American Academy of Orthopaedic Surgeons defined the acceptable threshold for elective safe surgery as a body mass index (BMI) under 40 due to the increased risk of complications. A consequence of this recommendation has been a hard cutoff based on BMI, which restricts access to care for an increasingly large and diverse population. There is an improved understanding that excess adipose tissue confers additional risk for postoperative complications, including infection, through mechanical and physiologic mechanisms. But, it is unclear if BMI is an accurate indicator of adiposity in total joint arthroplasty (TJA) patients and, thus, whether BMI is capturing clinically relevant information in obese patients. Our objective was to determine the relationship between peri-incisional adiposity (PIA) and BMI in a consecutive series of diverse primary TJA patients. MethodsA consecutive series of patients indicated for primary TJA were preoperatively evaluated. For each patient, the following variables were collected: BMI and measures of PIA on radiographs and ultrasounds. ResultsIn THA patients (N = 99), Pearson’s correlation coefficient (r) = 0.436, which indicates a moderate correlation between BMI and adiposity. In total knee arthroplasty patients (N = 271), r = 0.395 for femoral PIA (FPIA) and r = 0.249 for tibial PIA, which indicates a weak correlation between BMI and adiposity measured on radiography. In total knee arthroplasty patients, r = 0.560 for femoral PIA and r = 0.544 for tibial PIA, which indicates a moderate correlation between BMI and adiposity measured on ultrasound. ConclusionsQuantification of obesity has become a common practice in the preoperative evaluation of primary TJA patients. The intent is to determine the magnitude of adipose tissue, which is one of the main drivers of postoperative complications in obesity. The BMI is ubiquitously used as a proxy for obesity due to its simplicity of attainment and calculation. We report that BMI has a weak-to-moderate association with PIA in this population. These findings indicate that BMI may not accurately represent the condition of peri-incisional adipose tissue and, thus, is not capturing the relevant obesity data for preoperative risk stratification in primary TJA patients. Level of evidenceIII.

Patient-reported Physical and Mental Health Outcomes Following Lumbar Spinal Fusion versus Total Hip and Total Knee Replacement

BackgroundTotal hip and knee arthroplasty (THA/TKA) are reliable surgical procedures for alleviating pain and optimizing function. Spinal fusion has also been shown to be beneficial, however the comparative benefit of THA/TKA to lumbar spinal fusion is incompletely understood. MethodsThis study analyzed a single-center database of patients who underwent primary lumbar spinal fusion, elective primary TKA, or THA. PROMs included Veterans-Rand (VR12) Physical and mental component score (PCS/MCS) for TKA/THA and PROMIS (Patient-Reported Outcomes Measurement Information System) global mental and physical health (GPH/GMH) for spinal fusion. Results356 patients who underwent TKA, 290 underwent THA, and 125 underwent spinal fusion were included. Joint replacement patients were older, with higher body mass index in the TKA group. Spine patients had a lower improvement in physical health than the joint patients (TKA: 9.4 ± 11.2, THA: 15.2 ± 11.2, Spine: 6.2 ± 8.7, p<.001) and a lower proportion of patients reaching the minimal clinically important difference (MCID). Spine patients had higher GMH improvements compared to TKA patients (TKA: -1.1 ± 10.7, THA: 1.1 ± 11.9, Spine: 1.8 ± 8.4, p=.009) and the highest proportion of patients reaching the MCID. ConclusionSpinal fusion, total knee arthroplasty, and total hip arthroplasty all significantly improved PROMs at 1-year follow-up. At baseline, spinal fusion patients had better physical function scores and worse mental health scores compared to joint arthroplasty patients, while spinal fusion resulted in mean smaller gains in patient reported physical function and higher gains in patient reported mental health function compared to arthroplasty.

Perioperative Short-Term Glucocorticoids Do Not Increase Incidence of Complications after Total Joint Arthroplasty in Patients with Rheumatoid Arthritis.

The safety and analgesic efficacy of perioperative glucocorticoids have been established for patients without rheumatoid arthritis. Therefore, our study aims to investigate whether similar benefits can be observed in patients with rheumatoid arthritis undergoing total joint arthroplasty. Specifically, we aim to explore the impact of perioperative glucocorticoid use on postoperative complications, opioid consumption, incidence of hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission in this patient population. Approval for the study protocol was obtained from the Medical Research Ethics Committee at Sichuan University, aligning with the principles outlined in the Declaration of Helsinki. We retrospectively analyzed a consecutive series of patients with rheumatoid arthritis who underwent total joint arthroplasty at our medical center between November 2009 and April 2021 and who were not on chronic glucocorticoid therapy before surgery. Those who received glucocorticoids at any time during hospitalization were compared to those who did not in terms of acute complications within 90 days after surgery as well as postoperative rescue opioid consumption, hypotension, and hyperglycemia during hospitalization. The two groups were also compared in terms of overall duration of hospitalization, all-cause mortality within 30 days, and readmission for any reason within 90 days. Continuous data were assessed for significance using the independent-samples t test. Categorical data were assessed using the Pearson chi-squared test. Of the 849 patients included in the analysis, 598 administered perioperative glucocorticoids and 251 did not. Prior to surgery, the two groups did not differ significantly in any clinicodemographic variable that we examined. The incidence of acute postoperative complications (2.3% vs. 4.0%, p = 0.187) and acute postoperative infection (2.0% vs. 2.8%, p = 0.482) was comparable between those who received perioperative glucocorticoids and those who did not, but the former group exhibited a significantly lower incidence of rescue opioid use (17.9% vs. 44.6%, p < 0.001) as well as significantly lower total rescue opioid consumption (4.7 ± 2.1 mg vs. 8.9 ± 4.6 mg, p < 0.001). However, the two groups showed similar incidences of postoperative hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission. Perioperative glucocorticoids may reduce the need for rescue opioids after total joint arthroplasty of rheumatoid arthritis patients, without increasing the incidence of acute complications, hypotension or hyperglycemia.

Cross-Combination Analyses of Random Forest Feature Selection and Decision Tree Model for Predicting Intraoperative Hypothermia in Total Joint Arthroplasty

BackgroundIn total joint arthroplasty patients, intraoperative hypothermia (IOH) is associated with perioperative complications and an increased economic burden. Previous models have some limitations and mainly focus on regression modeling. Random forest (RF) algorithms and decision tree modeling are effective for eliminating irrelevant features and making predictions that aid in accelerating modeling and reducing application difficulty. MethodsWe conducted this prospective observational study using convenience sampling and collected data from 327 total joint arthroplasty patients in a tertiary hospital from March 4, 2023, to September 11, 2023. Of those, 229 patients were assigned to the training and 98 to the testing sets. The Chi-square, Mann–Whitney U, and t-tests were used for baseline analyses. The feature variables selection used the RF algorithms, and the decision tree model was trained on 299 examples and validated on 98. The sensitivity, specificity, recall, F1 score, and area under the curve were used to test the model’s performance. ResultsThe RF algorithms identified the preheating time, the volume of flushing fluids, the intraoperative infusion volume, the anesthesia time, the surgical time, and the core temperature after intubation as risk factors for IOH. The decision tree was grown to 5 levels with 9 terminal nodes. The overall incidence of IOH was 42.13%. The sensitivity, specificity, recall, F1 score, and area under the curve were 0.651, 0.907, 0.916, 0.761, and 0.810, respectively. The model indicated strong internal consistency and predictive ability. ConclusionsThe preheating time, the volume of flushing fluids, the intraoperative infusion volume, the anesthesia time, the surgical time, and the core temperature after intubation could accurately predict IOH in total joint arthroplasty patients. By monitoring these factors, the clinical staff could achieve early detection and intervention of IOH in total joint arthroplasty patients.

The Five-Year Incidence of Progression to Osteoarthritis and Total Joint Arthroplasty in Patients Prescribed Glucagon-Like Peptide 1 Receptor Agonists

BackgroundResearch has suggested that glucagon-like peptide-1 receptor agonists (GLP-1-RAs) may have therapeutic effects on osteoarthritis of the hip and knee, in addition to managing diabetes and obesity. However, there is a lack of understanding regarding the association between GLP-1-RA use and the diagnosis of osteoarthritis (OA) of the hip and knee. MethodsA collaborative network analytics platform was queried for obese diabetic (n = 1,094,198), obese nondiabetic (n = 916,235), and nonobese diabetic (n = 157,305) patients who had an index visit between 2015 and 2017. Patients who had pre-existing hip and/or knee OA were excluded. A 1:1 propensity score matching was used to balance GLP-1-RA use in stratified cohorts for age, sex, race, body mass index, and hemoglobin A1c. The primary outcomes were rates of progression to hip OA, knee OA, major joint injections, total hip arthroplasty, and total knee arthroplasty. Cox proportional hazards models determined hazard ratios (HRs) between cohorts prescribed and not prescribed GLP-1-RAs. ResultsAll patients had a five-year follow-up. Rates of progression to hip and knee OA were higher among the GLP-1-RA users in both obese diabetic (hip HR: 1.63, 95% confidence interval [CI]: 1.46 to 1.82; knee HR: 1.52, CI: 1.41 to 1.64) and nonobese diabetic (hip HR: 1.78, CI: 1.50 to 2.10; knee HR: 1.58, CI: 1.39 to 1.80) cohorts. These diabetic cohorts received higher rates of major joint injections, though there was no difference in rates of total hip arthroplasty or total knee arthroplasty. No differences in five-year outcomes were seen when comparing obese, nondiabetic patients who were prescribed GLP-1-RAs with obese, nondiabetic patients not exposed to GLP-1-RAs. ConclusionsThis five-year analysis found a greater risk of progression to hip and knee OA among obese and non-obese diabetic GLP-1-RA users. Further studies should explore GLP-1-RA effects upon glucose management, weight loss, and lower extremity arthritis development. Level of EvidenceIII, retrospective cohort study.

Incidence and associated factors of delirium after primary total joint arthroplasty in elderly patients: A systematic review and meta-analysis.

A total of 1.5% to 20.2% of total joint arthroplasty patients experience delirium. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of delirium after primary total joint arthroplasty (TJA). A comprehensive search encompassing Medline, Embase, and the Cochrane central database was conducted, incorporating studies available up to June 2023. We systematically reviewed research on the risk factors contributing to delirium following TJA in elderly patients, without language restrictions. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa Scale. Data synthesis through pooling and a meta-analysis were performed to analyze the findings. A total of 23 studies altogether included 71,095 patients with primary TJA, 2142 cases of delirium occurred after surgery, suggesting the accumulated incidence of 3.0%. The results indicated that age, current smoker, heavy drinker, mini-mental state examination score, hypertension, diabetes mellitus, chronic kidney disease, history of stroke, coronary arterial disease, dementia, history of psychiatric illness, American Society of Anesthesiologists physical status III-IV, general anesthesia, anesthesia time, operative time, intraoperative blood loss, blood transfusion, β-blockers, ACEI drugs, use of psychotropic drugs, preoperative C-reactive protein level, and preoperative albumin level were significantly associated with postoperative delirium after primary TJA. Related prophylaxis strategies should be implemented in the elderly involved with above-mentioned risk factors to prevent delirium after primary TJA.

Initiating chemotherapy in joint arthroplasty patients increases the risk of periprosthetic joint infections.

Total Joint Arthroplasties (TJAs) are becoming more popular, resulting in a growing economic burden due to potential postoperative complications, with periprosthetic joint infections (PJIs) playing a significant role. The effect of immunosuppression on PJI risk, particularly in cancer patients following chemotherapy, is unknown. The hypothesis of this study investigated whether chemotherapy increases PJI rates in patients who received post-arthroplasty chemotherapy within one year of surgery. Data from the M161Ortho dataset of PearlDiver patient records database were utilized using ICD-9, ICD-10, and CPT codes. The cohort includes Total Knee Arthroplasty (TKA), Total Hip Arthroplasty (THA), and Total Shoulder Arthroplasty (TSA) patients who underwent post-arthroplasty chemotherapy within one year after surgery between 2010 and 2022. Patients in the matched control group did not receive post-arthroplasty chemotherapy. Pre-arthroplasty chemotherapy recipients, PJI, and post-op first year revisions were excluded. Analyses including the linear logistic regression were performed via R statistical software. Totally, 17,026 patients (8,558 TKAs, 6,707 THAs, and 1,761 TSAs) were included. At two (OR = 1.59, p = 0.034), three (OR = 1.57, p = 0.009), and four (OR = 1.40, p = 0.032) years for TKA, and two (OR = 2.27, p = 0.008), three (OR = 2.32, p < 0.001), and four (OR = 2.25, p0.001) years for THA, PJI rates were significantly higher in the chemotherapy group. TSA patients had a significant rise in PJI after four years (OR = 2.20, p = 0.031). This study reveals a possible relationship between postoperative chemotherapy and an increased incidence of PJI in patients with arthroplasty. Chemotherapy suppresses the immune system, rendering patients more vulnerable to infections. Additional research is required to confirm these findings.

Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients

BackgroundThe prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states. MethodsWe prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. ResultsSeven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%). ConclusionsThe use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.

The rapid recovery study: Cyclobenzaprine's effect on recovery following joint arthroplasty

IntroductionSkeletal muscle relaxants have previously not been examined in multimodal anesthesia regimens following joint arthroplasty. We sought to evaluate cyclobenzaprine's effect on postoperative opioid consumption as well as surgical recovery following joint arthroplasty. Materials and methodsIn this retrospective cohort study, 471 patients undergoing 554 joint arthroplasty procedures were evaluated. Patients were divided into cohorts who did and did not receive cyclobenzaprine postoperatively, and postoperative opioid consumption and functional recovery measures were recorded in each cohort. ResultsIn the unadjusted model, the cyclobenzaprine cohort experienced a 1.11 increase in pain scores on postoperative day zero (95% CI (0.60, 1.62), p < 0.0001). After adjusting for age, sex, BMI, CCI, perioperative MME, laterality, procedure, anesthesia, pre-op opioid use, pre-operative other controlled substance uses and pre-op benzodiazepine use, the cyclobenzaprine cohort's pain scores were 1.08 units higher at rest (95% CI (0.59, 1.56), p < 0.0001) and 1.25 units higher with activity on postoperative-day-zero (95% CI (0.78, 1.72), p < 0.0001). Both cohorts experienced statistically insignificantly different changes in mobility scores between postoperative day zero and postoperative day one, range of motion at 6 and 12 weeks, and readmission in <90 days. Postoperative morphine milliequivalents were insignificantly different between cohorts after controlling for pain in all models (base model mean ratio: 1.06, 95% CI (0.87,1.29), p = 0.5599) (Full model mean ratio: 1.09, 95% CI (0.91,1.30), p = 0.3608). ConclusionsCyclobenzaprine shows utility in a multimodal anesthetic approach after joint arthroplasty in patients with higher baseline pain.