Outcomes Of Total Joint Arthroplasty Research Articles

Optimal inputs for machine learning models in predicting total joint arthroplasty outcomes: a systematic review.

Machine learning (ML) models may offer a novel solution to reducing postoperative complication rates and improving post-surgical outcomes after total joint arthroplasty (TJA). However, the variety of different ML models that exist paired with the increasing number of potential inputs can make the implementation of this tool challenging. Therefore, we conducted a systematic review to assess the most optimal inputs of different ML models in predicting postoperative (1) medical outcomes, (2) orthopedic outcomes, and (3) patient-reported outcome measures (PROMs) after total joint arthroplasty. The PubMed, MEDLINE, EBSCOhost, and Google Scholar databases were utilized to identify all studies evaluating ML models predicting outcomes following TJA between January 1, 2000, and June 23, 2023 (PROSPERO study protocol registration: CRD42023437586). The mean risk of bias in non-randomized studies-of interventions score, was 13.8 ± 0.5. Our initial query yielded 656 articles, of which 25 articles aligned with our aims, examining over 20 machine learning models and 1,555,300 surgeries. The area under the curve (AUC), accuracy, inputs, and the importance of each input were reported. Twelve studies evaluating medical complications with 13ML models reported AUCs ranging from 0.57 to 0.997 and accuracy between 88% and 99.98%. Key predictors included age, hyper-coagulopathy, total number of diagnoses, admission month, and malnutrition. Five studies evaluating orthopedic complications with 10ML models reported AUCs from 0.49 to 0.93 and accuracy ranging from 92 to 97%, with age, BMI, CCI, AKSS scores, and height identified as key predictors. Ten studies evaluating PROMs comprising of 12 different ML models had an AUC ranging from 0.453 to 0.97 ranked preoperative PROMs as the post-predictive input. Overall, age was the most predictive risk factor for complications post-total joint arthroplasty (TJA). These studies demonstrate the predictive capabilities of these models for anticipating complications and outcomes. Furthermore, these studies also highlight ML models' ability to identify non-classical variables not commonly considered in addition to confirming variables known to be crucial. To advance the field, forthcoming research should adhere to established guidelines for model development and training, employ industry-standard input parameters, and subject their models to external validity assessments.

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.

Genetic and Modifiable Risk Factors for Postoperative Complications of Total Joint Arthroplasty: A Genome-Wide Association and Mendelian Randomization Study.

Background: Total joint arthroplasty (TJA) is an orthopedic procedure commonly used to treat damaged joints. Despite the efficacy of TJA, postoperative complications, including aseptic prosthesis loosening and infections, are common. Moreover, the effects of individual genetic susceptibility and modifiable risk factors on these complications are unclear. This study analyzed these effects to enhance patient prognosis and postoperative management. Methods: We conducted an extensive genome-wide association study (GWAS) and Mendelian randomization (MR) study using UK Biobank data. The cohort included 2964 patients with mechanical complications post-TJA, 957 with periprosthetic joint infection (PJI), and a control group of 398,708 individuals. Genetic loci associated with postoperative complications were identified by a GWAS analysis, and the causal relationships of 11 modifiable risk factors with complications were assessed using MR. Results: The GWAS analysis identified nine loci associated with post-TJA complications. Two loci near the PPP1R3B and RBM26 genes were significantly linked to mechanical complications and PJI, respectively. The MR analysis demonstrated that body mass index was positively associated with the risk of mechanical complications (odds ratio [OR]: 1.42; p < 0.001). Higher educational attainment was associated with a decreased risk of mechanical complications (OR: 0.55; p < 0.001) and PJI (OR: 0.43; p = 0.001). Type 2 diabetes was suggestively associated with mechanical complications (OR, 1.18, p = 0.02), and hypertension was suggestively associated with PJI (OR, 1.41, p = 0.008). Other lifestyle factors, including smoking and alcohol consumption, were not causally related to postoperative complications. Conclusions: The genetic loci near PPP1R3B and RBM26 influenced the risk of post-TJA mechanical complications and infections, respectively. The effects of genetic and modifiable risk factors, including body mass index and educational attainment, underscore the need to perform personalized preoperative assessments and the postoperative management of surgical patients. These results indicate that integrating genetic screening and lifestyle interventions into patient care can improve the outcomes of TJA and patient quality of life.

Association between bariatric surgery and outcomes of total joint arthroplasty: a meta-analysis.

Association between bariatric surgery and outcomes of total joint arthroplasty: a meta-analysis.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

Statin use in total joint arthroplasty: a systematic review

Introduction: There has been increased interest in the use of Statins in total hip and knee arthroplasty (THA and TKA) patients to improve outcomes and reduce postoperative complications. This study was performed to systematically review the evidence on Statin use in total joint arthroplasty, specifically its benefits and complications. Methods: Adhering to the PRISMA guidelines, a systematic review of PubMed, Embase, Scopus, Web of Science, and the Cochrane database was performed to find studies reporting on the effects of Statin use on outcomes of THA and TKA. Two authors independently selected relevant papers to include. Results: A total of 18 papers were included in the final analysis. Most were retrospective studies, with heterogeneous patient selection and outcome measures. The evidence on the risks and benefits of Statin use on outcomes of total joint arthroplasty was very limited and heterogeneous. Studies were focusing on perioperative cardiac outcomes, clinical outcomes and complications, renal, pulmonary, and gastrointestinal outcomes. Due to the heterogeneity of reported data, a formal meta-analysis was not possible. Conclusions: There is some evidence in the literature suggesting that perioperative use of Statins, especially in Statin-naïve patients, may reduce cardiac (e.g. atrial fibrillation) and noncardiac (e.g. delirium) complications, while not increasing the risk of muscle or liver toxicity. The authors also found low levels of evidence that Statin use may reduce the long-term risk for revision surgery and osteolysis.

The impact of diabetes status on pain and physical function following total joint arthroplasty for hip and knee osteoarthritis: variation by sex and body mass index

Few studies have examined diabetes impact on total joint arthroplasty (TJA) outcomes, with variable findings. We investigated the association between diabetes and post-TJA physical function and pain, examining whether diabetes impact differs by sex and BMI. Patient sample completed questionnaires within 3 months prior to hip or knee TJA for osteoarthritis (OA) and 1-year post-surgery. Surgical ‘non-response’ was defined as < 30% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function at 1-year. Two adjusted logistic regression models were estimated: (1) excluding, (2) including an interaction between diabetes, sex and BMI. The sample (626 hip, 754 knee) was 54.9% female, had mean BMI of 30.1, 13.0% reported diabetes. In adjusted models excluding an interaction, diabetes was not associated with non-response. However, a significant 3-way interaction (physical function: p = 0.003; pain: p = 0.006) between diabetes, sex, and BMI was found and was associated with non-response: non-response probability increased with increasing BMI in men with diabetes, but decreased with increasing BMI in women in diabetes. Findings suggest uncertainty in diabetes impact may be due to differential impacts by sex and BMI. A simple consideration of diabetes as present vs. absent may not be sufficient, with implications for the large TJA population.

We Should Weigh the Benefits and Costs of Preoperative Medical Evaluation for Total Joint Arthroplasty: Commentary on an article by Rakesh R. Veerareddy, MBBS, et al.: "The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes. An Observational Study".

We Should Weigh the Benefits and Costs of Preoperative Medical Evaluation for Total Joint Arthroplasty: Commentary on an article by Rakesh R. Veerareddy, MBBS, et al.: "The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes. An Observational Study".

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Mental Health and Housing Status-Part Five of the Movement Is Life Special ONJ Series.

Mental health and housing status have the potential to impact total joint arthroplasty (TJA) outcomes and are common TJA eligibility criteria that prevent patients from receiving surgery. Our aim was to formulate recommendations for how nurse navigators can assist patients with managing mental health and housing concerns. Through discussions with nurse navigators and a literature search across two databases, we gathered information regarding the optimization of mental health and housing status among TJA patients. We observed a lack of standardized protocols for addressing these concerns and literature supporting an increased focus on mental health and housing status, indicating the potential for greater nurse navigator involvement in developing and implementing protocols. We recommend nurse navigators use screening tools to identify mental health and housing concerns and offer the suggested resources to support patients in an effort to improve postoperative outcomes and decrease surgical risks.

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study.

A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Site of Service Disparities Exist for Total Joint Arthroplasty.

The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

Patients' perspective of fast-track total joint arthroplasty: a systematic review.

The introduction of fast-track protocols decreased length of hospital stay and improved rehabilitation and outcomes in total joint arthroplasty. Despite improved clinical results published in many papers, the patient perspective of these protocols is less investigated. Purpose of this study was to explore the patient perspective of fast-track protocols in arthroplasty. A systematic search for articles of patient experiences in total hip, knee, and shoulder arthroplasty was conducted using EMBASE, MEDLINE, Cochrane, and Web-of-Science for articles published from inception to February 14, 2023. In total 12 studies were included involving 672 patients. Most patients were satisfied with short length of hospital stay and preferred rehabilitation at home with relatives for support. Various experiences were reported regarding pain and postoperative out of hospital physical therapy. Frequently, feelings of insecurity were reported because of lack of personalized information. Based on current qualitative literature, patients are satisfied with short length of hospital stay in fast-track total joint arthroplasty. Improvements in personalized information and physical therapy protocols is needed.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis

BackgroundThis study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. MethodsA retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student’s T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. ResultsOur study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. ConclusionsThere was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non–total joint surgeons, although their patient population was more complex. Level of evidenceIII.

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.

Total Joint Arthroplasty in Patients With Lymphedema as Compared to a Propensity-Matched Control Cohort

BackgroundLymphedema is rare in arthroplasty patients but has been associated with a higher complication rate. This study sought to determine the outcomes of total joint arthroplasty in patients with lymphedema as compared to a matched control cohort. MethodsTreatment-control propensity matching was implemented on 335 patients following total knee or hip arthroplasty generating 5-patient sets of one patient with presurgery lymphedema (67 total) to 4 patients without presurgery lymphedema (268 total) and matched on age, sex, and surgery year. Body mass index and presence of diabetes were controlled using multivariable generalized estimating equations. ResultsIn the lymphedema cohort, 1 patient (1.5%) had a deep vein thrombosis within 90 days of their surgery, 36 (53.7%) were discharged to a rehabilitation center, 16 (23.9%) had a readmission, 14 (20.9%) were admitted to the emergency room within 90 days, 6 (9.0%) experienced infection, and 6 (9.0%) had a revision/reoperation. Lymphedema significantly increased emergency room admission within 90 days (odds ratio [OR] 4.56, P = .01) and non-home discharge (OR 4.14, P < .01), affected readmission within 90 days (OR 2.21, P = .09), revision/reoperation (OR 2.82, P = .09), and no effect on deep vein thrombosis within 90 days (OR 0.57, P = .45), postsurgical infection (OR 1.47, P = .45), length of stay (OR 0.00, P = .99), operative time (OR 0.04, P = .38), or estimated blood loss (OR 0.09, P = .47), after adjusting for various factors. ConclusionsPreoperative lymphedema is a significant risk factor for patients who are undergoing total joint arthroplasty. Preoperative and postoperative modalities should be utilized to help control lymphedema and mitigate these increased risks.

Costs and Outcomes of Total Joint Arthroplasty in Medicare Beneficiaries Are Not Meaningfully Associated with Industry Payments.

Prior studies have demonstrated that industry payments affect physician prescribing patterns, but their effect on orthopaedic surgical costs is unknown. This study examines the relationship between industry payments and the total costs of primary total joint arthroplasty, as well as operating room cost, length of stay, 30-day mortality, and 30-day readmission. Open Payments data were matched across a 20% sample of Medicare-insured patients undergoing primary elective total hip arthroplasty (THA) (n = 130,872) performed by 7,539 surgeons or primary elective total knee arthroplasty (TKA) (n = 230,856) performed by 8,977 surgeons from 2013 to 2015. Patient, hospital, and surgeon-specific factors were gathered. Total and operating room costs, length of stay, mortality, and readmissions were recorded. Multivariable linear and logistic regression models were used to identify the risk-adjusted relationships between industry payments and the primary and secondary outcomes. In this study, 96.7% of THA surgeons and 97.4% of TKA surgeons received industry payments. After multivariable risk adjustment, for each $1,000 increase in industry payments, the total costs of THA increased by $0.50 (0.003% of total costs) and the operating room costs of THA increased by $0.20 (0.003% of total costs). Industry payments were not associated with TKA cost. Industry payments were not associated with 30-day mortality after either THA or TKA. Higher industry payments were independently associated with a marginal decrease in the length of stay for patients undergoing THA (0.0045 days per $1,000) or TKA (0.0035 days per $1,000) and a <0.1% increase in the odds of 30-day readmission after THA for every $1,000 in industry payments. The median total THA costs were $300 higher (p < 0.001), whereas the median TKA costs were $150 lower (p < 0.001), for surgeons receiving the highest 5% of industry payments. These surgical procedures were more often performed in large urban areas, in hospitals with a higher number of beds, with a higher wage index, and by more experienced surgeons and were associated with a 0.4 to 1-day shorter length of stay (p < 0.001). Although most arthroplasty surgeons received industry payments, a minority of surgeons received the majority of payments. Overall, arthroplasty costs and outcomes were not meaningfully impacted by industry relationships. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Patients Who Have a Prior History of Pulmonary Embolism Require Increased Postoperative Care Following Total Joint Arthroplasty

BackgroundThis study examined the effect of prior pulmonary embolism (PE) on total joint arthroplasty (TJA) outcomes. MethodsWe reviewed patients who had a prior PE undergoing TJA at a single tertiary medical center between January 1, 2012 and January 1, 2021. There were 177 TJA patients who had a prior PE who underwent 1:3 propensity-matching to patients without a history of prior PE. Bivariable and multivariable analyses were performed. Changes over time were evaluated. ResultsPatients undergoing total knee arthroplasty who had a prior PE had more complications (25.3% versus 2.0%, P < .001), and postoperative PE (17.3% versus 0.0%, P < .001).and longer hospitalizations (3.15 versus 2.32 days, P = .006). Patients undergoing total hip arthroplasty who had a prior PE demonstrated more complications (14.7% versus 1.77%, P < .001) more postoperative PE (17.3% versus 0.0%, P < .001), and longer hospitalizations (3.30 versus 2.11 days, P < .001). Over the study, complication rates and hospitalizations lengths remained elevated in patients who had a prior PE. On multivariate analyses, prior PE was associated with longer hospitalizations (β: 0.67, P = .015) and increased complications (odds ratio [OR]: 9.44, P < .001) among total hip arthroplasty patients. Total knee arthroplasty patients had increased readmission (OR: 4.89, P = .003) and complication rates (OR: 21.4, P < .001). ConclusionsPatients undergoing TJA who had a prior PE are at higher risk of requiring postoperative care. Therefore, thorough preoperative evaluation must be implemented, especially in clinical environments lacking resources for acute care escalation.

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.

Outcomes of Total Joint Arthroplasty Subsequent to Ostomy: A Case Series

BackgroundOstomy surgery is associated with a high rate of postoperative complications and poses several theoretical concerns for subsequent total joint arthroplasty (TJA). There is concern that ostomy may negatively impact nutrition or increase risk of known gastrointestinal (GI) complications such as obstruction, constipation, or diarrhea, particularly with the use of postoperative opioids. There is also concern that the open nature of the ostomy may increase the risk of infection. This case series reports outcomes and assesses the risk associated with TJA in patients with previous surgical history of intestinal ostomy. MethodsThis is an institutional review board-approved retrospective case series of patients with surgical history of ostomy who underwent total hip or total knee arthroplasty. Cohort consisted of 14 cases in 10 patients and was examined to report individual TJA and ostomy procedural details and outcomes. ResultsOf the 14 cases, none required GI clearance or prophylaxis outside of standard perioperative antibiotics prior to TJA surgeries, and all TJAs resulted in good outcomes. Four cases (29%) had a complication, although only 2 of these were GI complications and none were life-threatening or required further surgery. The first of the 2 experienced increased ostomy output, and symptoms were resolved promptly with rehydration. The second experienced decreased ostomy output, and symptoms were resolved promptly with changes in prn pain medications. Other complications were postoperative urinary tract infection and syncopal episode. ConclusionsTJA can be performed safely in the setting of ostomy with major consideration being risk of diarrhea or constipation during postoperative period.

History of Diabetic Foot Ulcer is Associated With Increased Risk of Prosthetic Joint Infection and Sepsis After Total Joint Arthroplasty

BackgroundDiabetic 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. MethodsUsing 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). ResultsDFU 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. ConclusionDFU 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.