Total Joint Arthroplasty Cases Research Articles

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population.

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7]years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p<0.05), 44% lower LOS (1.4 vs 2.5days, p<0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p<0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes.

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types. The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status. Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001). Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparing five equations to calculate estimated glomerular filtration rate to predict acute kidney injury following total joint arthroplasty

BackgroundAcute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA.MethodsThe National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations.ResultsSeven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation.ConclusionsPreoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients.

Incidental Findings in Low-Dose Full-Body Imaging Taken for Total Hip and Knee Arthroplasty

AbstractDetection of incidental findings (IFs) in preoperative imaging for total joint arthroplasty (TJA) patients may lead to additional testing, cost, and surgical delay. The purpose of this study is to identify the incidence and clinical significance of IFs on preoperative low-dose full-body imaging (LFI) in the total joint population. Furthermore, we aim to determine whether these findings lead to additional imaging, delay, or cancelation in TJA cases. A retrospective review of 2,183 patients planned for total hip arthroplasty or total knee arthroplasty, who had preoperative LFI imaging obtained from 2013 to 2020 was conducted. LFI radiographic reports were reviewed to identify any flagged radiographs. Flagged IFs were divided into thoracic, spinal, lower limb, and abdominal IFs. Charts were reviewed to identify if any additional imaging was completed, the case was delayed or canceled, or a new pathology requiring continued follow-up or treatment was discovered. Of the 2,183 LFI images taken prior to TJA, 41 cases qualified as having IF (1.9%, 41/2,183), 18 thoracic, 11 spinal, 11 lower limb, and 1 abdominal. Overall, 15 (0.7%, 15/2,183) IF cases were clinically determined to require at least one additional form of imaging. Two had a significant finding; a schwannoma near the distal femoral shaft and a squamous cell carcinoma of the lung. Three TJA cases were delayed, and no cases were cancelled due to the IFs. The possible increase in IF detection by preoperative LFI does not greatly impact TJA case completion. Though rare, providers should pay close attention as clinically significant IFs can be discovered and lead to early treatment. This was a retrospective cohort study with level III evidence.

Three Dimensional Printing as an Aid for Pre-operative Planning in Complex Cases of Total Joint Arthroplasty: A Case Series

PurposeDigital templating is an essential aspect of pre-operative planning for total joint arthroplasty procedures. For complex cases of joint reconstruction, the standard templating software is insufficient to achieve the desired accuracy. 3D printing significantly aids the pre-operative planning in complicated cases of joint reconstruction and offers immense potential towards improving outcomes in these cases. The purpose of the present study is to present the various ways in which 3D printing has aided our department in facilitating complex cases of lower extremity reconstruction. MethodsData was retrospectively retrieved for all patients that underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) with the aid of 3D printing technology at our institution between January 2016–February 2021. Patient pain was determined before and after surgery using the visual analogue scale (VAS). Patient reported outcome measures (PROMs) were additionally analyzed using the hip disability and osteoarthritis outcome score (HOOS) and knee injury and osteoarthritis outcome score (KOOS). ResultsThe final study population consisted of 39 patients that underwent TKA or THA procedures with the use of 3D printing. Twenty-four (61.5%) of the surgeries in the study were THA procedures, whereas 15 (38.5%) were TKA procedures. The average VAS for patients reduced from 8.4% before surgery to 5.4% after surgery (p < 0.001). The mean KOOS of patients that underwent TKA was 17.33 ± 9.33 (43%) and the mean HOOS of patients that underwent THA was 13.79 ± 6.6 (42%). ConclusionsThe following series demonstrates the ability by which 3D printing facilitates complex cases of hip and knee reconstruction. 3D printing offers an improvement in understanding of patient specific anatomy, enhancing patient outcomes. Departments should consider the use of 3D printing technology as an adjunct when performing complex cases of lower extremity reconstruction.

Can Patient-Reported Outcome Measurement Information System Measures Differentiate Patients Who Will Undergo Hip and Knee Total Joint Arthroplasty: A Retrospective Case-Control Study.

The Patient-Reported Outcome Measurement Information System (PROMIS) can be used to monitor patients in population-health-based programs. However, it is unknown which measures are most appropriate to differentiate patients who will undergo hip or knee total joint arthroplasty (TJA) in a cohort of patients with osteoarthritis. A retrospective cohort of new patients consulting for treatment from November 17, 2017 to April 20, 2020 (cases: hip: n= 157, knee: n= 112; randomly selected nonsurgical controls: hip: n= 314, knee: n= 224) was extracted from the electronic health record. We recorded demographics, comorbidity, and PROMIS scores for 8 domains (physical function, pain interference, pain intensity, anxiety, depression, sleep disturbance, ability to participate in social roles and activities, and fatigue). We performed descriptive statistics to characterize the cohorts and baseline PROMIS scores and conducted logistic regression models to determine which PROMIS domains differentiated patients undergoing hip and knee TJA. In univariate comparisons of PROMIS domains, the hip and knee surgical cohorts differed from controls in physical function (P < .01), pain interference (P < .01), and ability to participate in social roles and activities (P < .02). In logistic regression models informed by univariate analyses, PROMIS physical function was the only PROMIS measure to differentiate undergoing surgery in both hip and knee cohorts (P < .01). PROMIS physical function can differentiate TJA cases from nonsurgical controls in both hip and knee patients. These findings have implications for considering which PROMIS measures to administer in patients with hip and knee osteoarthritis.

Does Dosage or Duration of Concurrent Oral Corticosteroid Influence Elevated Risk of Postoperative Complications After Total Joint Arthroplasty?

This report seeks to clarify whether the dosage and duration of preoperative concurrent corticosteroid use influence postoperative complications after primary total joint arthroplasty (TJA). This retrospective single institutional study enrolled 1128 primary TJA cases, including 905 total hip arthroplasties and 223 total knee arthroplasties at a minimum 6 months of follow-up. Mean follow-up period was 51.9±34.1 months (range 6-146). Of all joints, 120 joints (10.6%) were associated with chronic concurrent oral corticosteroid use. Multivariate analysis was performed to identify whether chronic concurrent oral corticosteroid use elevated the risk of postoperative complications including surgical site infection/periprosthetic joint infection, delayed wound healing, periprosthetic fracture, and implant loosening. For chronic concurrent oral corticosteroid user, we determined whether the dosage and duration of preoperative concurrent corticosteroid use influenced postoperative complications and have an effective threshold for postoperative complications using receiver operating characteristic curve analysis. The multivariate analysis revealed that American Society of Anesthesiologist Physical Status 3 was an independent risk factor for postoperative complications, while concurrent oral corticosteroid use was not an independent risk factor. When we compared joints with (n= 13) and without (n= 107) postoperative complications in chronic concurrent oral corticosteroid user, there was no statistical difference in the dosage (P= .97) and duration (P= .69) between the 2 groups. Area under the curve values for the oral corticosteroid dosages and duration were 0.482 and 0.549, respectively. This study revealed that neither dosage nor duration of concurrent oral corticosteroid use was predictive of postoperative complications after TJA. American Society of Anesthesiologist Physical Status 3 is a major factor in postoperative complications after TJA.

Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic.

Despite known surgical volume reductions in 2020 during the height of the COVID-19 pandemic, no study has fully quantified the impact of the pandemic on the number of elective inpatient total hip (THA) and total knee arthroplasty (TKA) cases. The purpose of the present study was to analyze THA and TKA case volumes in the United States during the COVID-19 pandemic. The Premier Healthcare Database was utilized to identify adults undergoing primary elective THA or TKA from January 2017 to December 2020. The National Inpatient Sample was cross-referenced to provide nationwide representative sampling weights. Patients undergoing revision total joint arthroplasty (TJA) or non-elective surgery were excluded. Two quantitative models were created from both databases to estimate TJA case volume in 2020. Descriptive statistics were utilized to report monthly changes in elective TJA utilization throughout 2020. Univariate analyses were performed to compare differences between subgroups. From 2017 to 2019, it was estimated that 1,006,000 elective inpatient TJAs (64.2% TKA and 35.8% THA) were performed annually. In 2020, an estimated 526,000 to 538,000 cases (62.0% TKA and 38.0% THA) were performed, representing a 46.5% to 47.7% decrease in nationwide volume from the prior 3-year average. Moreover, the elective TJA case volume for April 2020 was 1.9% of the average for that month from 2017 through 2019. Subsequently, case volumes for May and June increased compared with the volumes for those months from 2017 through 2019. There was then a decrease in cases for July, corresponding with the "second wave" of COVID-19, followed by an additional steady monthly decline through December, corresponding with the "third wave." Finally, the elective TJA cases for December 2020 represented only 41.0% of the average case volume for that month from 2017 through 2019. In the midst of the 2020 COVID-19 pandemic, approximately 526,000 to 538,000 elective inpatient TJA cases were performed, representing a 46.5% to 47.7% decrease compared with the 3 previous years. The effects of the COVID-19 pandemic persisted through the end of that year, with decreased case volume through December 2020.

Comparison of mortality and serious complications in lower extremity total joint arthroplasty patients with aortic stenosis receiving spinal versus general anesthesia.

Aortic stenosis (AS) is a cardiac valvular lesion that can cause sudden death. Spinal anesthesia (SA) has been considered a relative contraindication in patients with AS. We sought to compare outcomes in patients with AS undergoing SA versus general anesthesia (GA) for lower extremity total joint arthroplasty (TJA). A retrospective chart review was conducted of elective, primary TJA cases between January 1, 2011, and November 30, 2017, at three tertiary care academic medical centers. Participants included 89 patients with AS undergoing TJA with SA, and 74 with AS undergoing TJA with GA. Primary endpoints included 90-day mortality, blood transfusion, hospital length of stay (LOS), and the 90-day incidence of deep vein thrombosis, pulmonary embolism, myocardial infarction, and stroke. Propensity score matching was utilized to assess differences in outcomes between patients receiving GA vs. SA. After matching, there were no significant differences in mortality (GA 0% vs. SA 1%; OR: 1.01 [0.98, 1.05]; P = 0.498), serious complications GA 2.2% vs. SA 0%; OR: 1.00 [0.95, 1.05]; P = 0.233), blood transfusion (GA 12.4% vs. 9% SA; OR: 1.01 [0.86, 1.19]; P = 0.751) within 90 days in the GA vs. SA groups, nor hospital LOS (GA mean 3.0 vs. SA mean 2.9,  0.3 [-0.11, 0.70]; P = 0.153). There were no differences in the incidence of mortality or serious complications in matched patients with AS undergoing elective primary lower extremity TJA under SA versus GA.

Predictors and Outcomes of Postoperative Hemoglobin of

Restrictive transfusion practices have decreased transfusions in total joint arthroplasty (TJA). A hemoglobin threshold of <8 g/dL is commonly used. Predictors of this degree of postoperative anemia in TJA and its association with postoperative outcomes, independent of transfusions, remain unclear. We identified predictors of postoperative hemoglobin of <8 g/dL and outcomes with and without transfusion in TJA. Primary elective TJA cases performed with a multimodal blood management protocol from 2017 to 2018 were reviewed, identifying 1,583 cases. Preoperative and postoperative variables were compared between patients with postoperative hemoglobin of <8 and ≥8 g/dL. Logistic regression and receiver operating characteristic curves were used to assess predictors of postoperative hemoglobin of <8 g/dL. Positive predictors of postoperative hemoglobin of <8 g/dL were preoperative hemoglobin level (odds ratio [OR] per 1.0-g/dL decrease, 3.0 [95% confidence interval (CI), 2.4 to 3.7]), total hip arthroplasty (OR compared with total knee arthroplasty, 2.1 [95% CI, 1.3 to 3.4]), and operative time (OR per 30-minute increase, 2.0 [95% CI, 1.6 to 2.6]). Negative predictors of postoperative hemoglobin of <8 g/dL were tranexamic acid use (OR, 0.42 [95% CI, 0.20 to 0.85]) and body mass index (OR per 1 kg/m2 above normal, 0.90 [95% CI, 0.86 to 0.94]). Preoperative hemoglobin levels of <12.4 g/dL in women and <13.4 g/dL in men best predicted postoperative hemoglobin of <8 g/dL. Overall, 5.2% of patients with postoperative hemoglobin of 7 to 8 g/dL and 95% of patients with postoperative hemoglobin of <7 g/dL received transfusions. Patients with postoperative hemoglobin of <8 g/dL had longer hospital stays (p < 0.001) and greater rates of emergency department visits or readmissions (p = 0.001) and acute kidney injury (p < 0.001). Among patients with postoperative hemoglobin of <8 g/dL, patients who received transfusions had a lower postoperative hemoglobin nadir (p < 0.001) and a longer hospital stay (p = 0.035) than patients who did not receive transfusions. Postoperative hemoglobin of <8 g/dL after TJA was associated with worse outcomes, even for patients who do not receive transfusions. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundTo date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA. MethodsWe systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty. ResultsWe included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types. ConclusionBased on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important. Level of EvidenceLevel III, meta-analysis.

Factors Associated With Perioperative Transfusion in Lower Extremity Revision Arthroplasty Under a Restrictive Blood Management Protocol

Approximately 37% of patients undergoing lower extremity revision total joint arthroplasty (TJA) receive allogeneic blood transfusions (ABTs), which are associated with increased risk of morbidity and death. It is important to identify patient factors associated with needing ABT because the health of higher-risk patients can be optimized preoperatively and their need for ABT can be minimized. Our goal was to identify the patient and surgical factors independently associated with perioperative ABT in revision TJA. We included all 251 lower extremity revision TJA cases performed at our academic tertiary care center from January 1, 2016, to December 31, 2018. We assessed the following factors for associations with perioperative ABT: patient age, sex, race, body mass index, preoperative hemoglobin level, and infection status (ie, infection as indication for revision TJA); use of vasopressors, tranexamic acid (TXA), surgical drains, tourniquets, and intraoperative cell salvage; and procedure type (hip versus knee), procedure complexity (according to the number of components revised), and surgical time. Multivariable regression was used to identify factors independently associated with perioperative ABT. The following characteristics were independently associated with greater odds of perioperative ABT: preoperative hemoglobin level (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5 to 2.2), infectious indication for revision (OR, 3.6; 95% CI, 1.3 to 9.7), and procedure complexity. TXA use was a negative predictor of ABT (OR, 0.47; 95% CI, 0.23 to 0.98). Compared with polyethylene liner exchanges, single-component revisions (OR, 14; 95% CI, 3.6 to 56) and dual-component revisions (OR, 7.8; 95% CI, 2.3 to 26) were associated with greater odds of ABT. Patients with preoperative anemia, those undergoing revision TJA because of infection, those who did not receive TXA, and those undergoing more complex TJA procedures may have greater odds of requiring ABT. We recommend preoperative optimization of the health of these patients to reduce the need for ABT. Level III, prognostic study.

Spinal anesthesia in a designated block bay for total joint arthroplasty: improving operating room efficiency.

Creating highly efficient operating room (OR) protocols for total joint arthroplasty (TJA) is a challenging and multifactorial process. We evaluated whether spinal anesthesia in a designated block bay (BBSA) would reduce time to incision, improve first case start time and decrease conversion to general anesthesia (GA). Retrospective cohort study on the first 86 TJA cases with BBSA from April to December 2018, compared with 344 TJA cases with spinal anesthesia performed in the OR (ORSA) during the same period. All TJA cases were included if the anesthetic plan was for spinal anesthesia. Patients were excluded if circumstances delayed start time or time to incision (advanced vascular access, pacemaker interrogation, surgeon availability). Data were extracted and analyzed via a linear mixed effects model to compare time to incision, via a Wilcoxon rank-sum test to compare first case start time, and via a Fisher's exact test to compare conversion to GA between the groups. In the mixed effect model, the BBSA group time to incision was 5.37 min less than the ORSA group (p=0.018). The BBSA group had improved median first case start time (30.0 min) versus the ORSA group (40.5 min, p<0.0001). There was lower conversion to GA 2/86 (2.33%) in the BBSA group versus 36/344 (10.47%) in the ORSA group (p=0.018). No serious adverse events were noted in either group. BBSA had limited impact on time to incision for TJA, with a small decrease for single OR days and no improvement on OR days with two rooms. BBSA was associated with improved first case start time and decreased rate of conversion to GA. Further research is needed to identify how BBSA affects the efficiency of TJA.

Cannabinoid and Opioid Use Among Total Joint Arthroplasty Patients: A 6-Year, Single-Institution Study.

Evidence is limited regarding cannabinoid use among total joint arthroplasty (TJA) patients, despite increased availability and popularity for treating chronic pain. The authors hypothesized that preoperative cannabinoid use increased and opioid use decreased during a 6-year interval in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, and also asked whether complications were associated with use of these substances. This retrospective, single-institution study reviewed electronic medical records and the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for TJA cases from 2012 through 2017. Primary outcomes were the prevalence and trends of active cannabinoid and opioid use, as determined by routine preoperative urine toxicology screening. Multivariable regression analyses were conducted to investigate a secondary outcome, whether there was an association between cannabinoid or opioid use and postoperative complications. A total of 1778 operations (1161 TKAs and 617 THAs) performed on 1519 patients were reviewed. The overall prevalence of pre-operative cannabinoid and opioid use was 11% and 23%, respectively. Comparing 2012 with 2017, cannabinoid use increased from 9% to 15% (P=.049), and opioid use decreased from 24% to 17% (P=.040). Cannabinoid users were more likely to be taking opioids than nonusers (P=.002). Controlling for age, sex, surgery type, and American Society of Anesthesiologists score, cannabinoid use was not associated with 90-day readmission, infection, reoperation, or other VASQIP-captured complications. Laboratory testing indicated a much higher prevalence of cannabinoid use among TJA patients than previously reported. During a 6-year period, cannabinoid use increased more than 60%, and opioid use decreased approximately 30%. These findings indicate that cannabinoid use did not appear to be associated with perioperative complications. [Orthopedics. 2021;44(1):e101-e106.].

Routine Basic Metabolic Panels Are Not Needed in All Patients After Primary Total Joint Arthroplasty: An Opportunity for Cost Reduction

BackgroundAs the incidence of total joint arthroplasty (TJA) increases, identifying methods for cost reduction is essential. Basic metabolic panels (BMPs) are obtained routinely after TJA. We aimed at assessing the prevalence of intervention secondary to abnormal BMPs after primary TJA and at identifying predictors of the need for postoperative BMPs. MethodsWe reviewed 802 cases (758 patients) of primary lower-extremity TJA performed from January 1 through December 31, 2018, at our tertiary care medical center. Patient characteristics, preoperative and postoperative BMPs, comorbidities, current medications, and in-hospital interventions were recorded. Age-adjusted Charlson Comorbidity Index (AA-CCI) values were calculated. Institutional costs of 1 BMP and of all BMPs not prompting intervention were calculated. We used multiple regression to identify independent predictors of in-hospital interventions secondary to abnormal postoperative BMPs. ResultsOur institutional BMP cost was $36. A total of 1032 postoperative BMPs were ordered; 958 (93%) prompted no intervention. This equated to $34,488 of avoidable BMP costs. We identified 27 cases (3.4%) requiring intervention secondary to abnormal BMPs. Independent predictors of intervention were preoperative renal dysfunction (ie, abnormal creatinine or glomerular filtration rate <60 mL/min) (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.8-22), number of current nephrotoxic medications (OR, 1.9; 95% CI, 1.3-2.9), and AA-CCI value (OR, 1.2; 95% CI, 1.0-1.5). ConclusionRoutine postoperative BMPs are unwarranted for most patients undergoing primary TJA. Testing may be reserved for those with renal dysfunction, those taking multiple nephrotoxic medications, or those with a high AA-CCI value.

Low Body Mass Index Is a Predictor for Mortality and Increased Length of Stay Following Total Joint Arthroplasty

BackgroundMalnutrition is a devastating condition which disproportionally affects the elderly population. Malnutrition furthers the pre-existing elevated risk for osteoarthritis in this population, thus exacerbating joint damage in patients and furthering the need for total joint arthroplasty (TJA). A marker for malnutrition is a low body mass index (BMI). The purpose of this study is to investigate whether low BMI status increased the risk for 2-year mortality or reoperation, 90-day readmission, or extended length of stay (LOS) following TJA. MethodsA retrospective study was performed using the Partners Arthroplasty Registry which contains data from 2016 to 2019. The registry was queried for primary total hip and primary total knee arthroplasty (TKA) patients that had a minimum of 2-years follow-up data. Demographic, surgical, and clinical outcome variables were obtained from these patients. The association between underweight BMI and objective outcomes of reoperation, 90-day readmission, mortality, and LOS was evaluated by univariate analysis followed by multiple logistic and linear regression analyses. ResultsThe final cohort used for analysis consisted of 4802 TJA cases. After accounting for potential confounders, underweight BMI was found to be independently associated with increased risk of mortality within 2 years following TJA (odds ratio 8.77) (95% confidence interval 2.14-32.0) and increased LOS of 0.44 days (95% confidence interval 0.02-0.86). ConclusionOur findings demonstrate that TJA patients with an underweight BMI experience an 8 times increased risk of 2-year mortality and an increased LOS of 0.44 days. Orthopedic surgeons should consider nutritional consultation and medical optimization in these high-risk patients prior to surgery.

The Cost of Poor Mental Health in Total Joint Arthroplasty

BackgroundThe purpose of this analysis was to evaluate (1) the impact of depression on resource utilization and financial outcomes in bundled total joint arthroplasty (TJA) and (2) whether similar effects are seen using baseline patient-reported outcome scores. MethodsAll elective bundled TJA cases from 2017 to 2018 at an academic system in the New York City area were included. We analyzed variables associated with cost differences seen between patients with and without depression, and between patients with low (<40th percentile) and high baseline (>60th percentile) Veterans RAND 12-Item Health Survey mental component scores (MCSs). We also analyzed whether depression or low MCS could predict worse financial outcomes. ResultsOur population included 825 patients, 418 with patient-reported outcome scores data. Depression was associated with higher rates of skilled nursing facility (SNF) discharge (42.7% vs 36.5%, P = .04), SNF payments ($16,200 vs $12,100, P = .0002), and average total episode costs ($31,000 vs $27,000, P = .04). Depression predicted bundle cost to be greater than target price (OR 1.82, 95% CI: 1.04-.16; P = .04) and SNF payment greater than 75th percentile (OR: 1.91; 95% CI: 1.00-3.65; P < .05). Similar effects were not seen using MCS. ConclusionThis is the first study to determine that depression predicts bundle cost greater than target price and SNF payment greater than 75th percentile. Our results emphasize the importance of accurate preoperative assessment of mental health in optimization of care, focusing on attenuating the increased SNF payments associated with depression. As similar effects were not seen using MCS, future studies should analyze the use of validated screening tools for depression, such as the PHQ-9, for more accurate assessments of patient mental health in TJA.

Routine Preoperative Nutritional Screening in All Primary Total Joint Arthroplasty Patients Has Little Utility

BackgroundNutritional optimization before total joint arthroplasty (TJA) may improve patient outcomes and decrease costs. However, the utility of serologic laboratory markers, including albumin, transferrin, and total lymphocyte count (TLC), as primary indicators of nutrition is unclear. We analyzed the prevalence of abnormal nutritional values before TJA and identified factors associated with them. MethodsWe retrospectively reviewed 819 primary cases of TJA performed at 1 institution from January to December 2018. Patient demographic characteristics were assessed for associations with abnormal preoperative nutritional values (albumin <3.5 g/dL, transferrin <200 mg/dL, and TLC <1.5 cells/μL3). Associations of comorbidities, American Society of Anesthesiologists Physical Status classification, and age-adjusted Charlson Comorbidity Index (CCI) with abnormal values were assessed with logistic regression. ResultsValues were abnormal for albumin in 21 cases (2.6%), transferrin in 26 cases (5.6%), and TLC in 185 cases (25%). Thirteen cases (1.7%) had abnormal values for 2 markers. Age was associated with abnormal albumin and TLC, and race with abnormal transferrin. Congestive heart failure, chronic kidney disease, pancreatic insufficiency, gastroesophageal reflux disease, osteoporosis, dementia, and CCI were associated with abnormal albumin; Parkinson disease and American Society of Anesthesiologists Physical Status with abnormal transferrin; and dementia, body mass index, cancer history, and CCI with abnormal TLC. ConclusionWe report low prevalence of and a low concordance rate among abnormal nutritional values before primary TJA. Our results suggest that routine testing of all healthy patients is not warranted before TJA.

Socioeconomic Status May Not Be a Risk Factor for Periprosthetic Joint Infection

BackgroundPeriprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, carrying significant economic and personal burden. The goal of this study is to use an established database to analyze socioeconomic variables and assess their relationship to PJI. Additionally, we sought to evaluate whether socioeconomic factors, along with other known risk factors of PJI, when controlled for in a statistical model affected the familial risk of PJI. MethodsWith approval from our Institutional Review Board we performed a population-based retrospective cohort study on all primary total joint arthroplasty cases of the hip or knee (n = 85,332), within a statewide database, between January 1996 and December 2013. We excluded 9854 patients due to age <18 years, missing data, history of PJI prior to index procedure, and no evidence of 2-year follow-up (excluding those with PJI). Cases that developed PJI following the index procedure (n = 2282) were compared to those that did not (n = 73,196). ResultsAfter adjusting for covariates, patients with Medicaid as a primary payer were at greater risk for experiencing PJI (relative risk 1.40, 95% confidence interval [CI] 1.08-1.82, P = .01). There was no difference in risk between the groups associated with education level or median household income (all, P > .05). First-degree relatives of patients who develop PJI (hazard ratio 1.66, 95% CI 1.23-2.24, P = .001) and first-degree and second-degree relatives combined (hazard ratio 1.39, 95% CI 1.09-1.77, P = .007) were at greater risk despite controlling for the above socioeconomic factors. ConclusionOur study provides further support that genetic factors may underlie PJI as we did observe significant familial risk even after accounting for socioeconomic factors and payer status. We did not find a correlation between education level or household income and PJI; however, Medicaid payees were at increased risk. Continued study is needed to define a possible heritable disposition to PJI in an effort to optimize treatment and possibly prevent this complication.

Operating Room Traffic in Total Joint Arthroplasty: One Simple Measure Toward Solving a Complex Problem.

Background:Periprosthetic joint infection remains a devastating complication of total joint arthroplasty (TJA). The literature suggests that unnecessary operating room (OR) traffic increases the risk of surgical site infection by increasing bacterial load in the OR. We attempted to determine whether the posting of “restricted access” signs on the outside and inside of OR doors during primary TJA procedures would result in a reduction of OR door openings.Methods:This prospectively designed, 2-phase study investigated the number of door openings per case for primary TJA. An independent observer collected data for each TJA case; the OR staff were blinded to the data collection to avoid bias. The first phase of this study recorded OR traffic without the use of “restricted access” signs. In the second, interventional phase of the study, OR traffic was monitored with the concomitant application of “restricted access” signs on the doors. The number of openings per case, from the time of incision to the time of dressing application, was collected.Results:The average number of openings per case during the first phase was 75, with 0.59 door openings per minute. The average number of openings per case during the second phase was 40, with 0.28 door openings per minute. Therefore, a 47% reduction in openings per case and a 53% reduction in the number of openings per minute during primary TJA cases were observed.Conclusions:We demonstrated that the simple addition of “restricted access” signs on the outside and inside of OR doors produced a significant reduction (p < 0.001) in OR traffic during primary TJA.Clinical Relevance:Posting signs can decrease door openings, potentially decreasing infection.