Unilateral Total Joint Arthroplasty Research Articles

Patient-Reported Outcome Measures are not a Valid Proxy for Patient Satisfaction in Total Joint Arthroplasty

BackgroundPatient-reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty. The objective of this study is to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome. MethodsOur institutional joint database was queried for patients who underwent primary, elective, unilateral total joint arthroplasty. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Oxford Hip Score, Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation, and University of California Los Angeles activity level rating. ResultsIn general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, Oxford Hip Score, KSCRS) compared to general health (Short Form-12), activity level (University of California Los Angeles activity level rating), or perception of normalcy (Single Assessment Numerical Evaluation). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, P < .001; KSCRS pain subscale, R = 0.49, P < .001). ConclusionThere is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction.

Depression Treatment Is Not Associated With Improved Patient-Reported Outcomes Following Total Joint Arthroplasty

BackgroundThe objective of this study was to investigate if there were differences in disease-specific, overall health, and activity outcomes after total joint arthroplasty (TJA) between treated and untreated depressed patients. MethodsPatients who underwent primary, elective, unilateral TJA were divided into 3 groups based on self-reported history of depression and treatment at the time of surgery: 1) patients without depression, 2) patients with treated depression, and 3) patients with untreated depression. The primary outcomes were the differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA activity rating scale up to 12 months postoperatively. A secondary outcome was the effect of depression treatment on patients’ perception of experiencing limitation in their activities due to depression. Univariate and mixed-effects model analyses were performed to control for potential confounding factors. ResultsThe prevalence of depression was 189/749 (25%). Compared to patients with treated depression, untreated patients had lower baseline SF-12 MCS (P < .001) and were more likely to have Medicaid insurance (P < .001). After controlling for potential confounding factors, there were no differences in either the absolute scores or net changes in any of the assessed outcomes at 12 months postoperatively among depressed patients regardless of treatment (P > .05). In addition, depression treatment did not affect patients’ perception of activity limitation (P = .412). ConclusionAlthough it is clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment does not necessarily imply resolution of depressive symptoms. Future studies should explore alternative interventions to reduce the health-related consequences of depression to optimize the outcomes of TJA.

Closed suction drainage following routine primary total joint arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a retrospective cohort study

BackgroundIn an enhanced recovery after surgery program, not placing a closed suction drain following routine primary total joint arthroplasty (TJA) is becoming more acceptable. However, the influence of drain use on transfusion rate and postoperative length of stay (PLOS) in TJA remains controversial. Therefore, we aimed to compare drain use with no drain in routine primary TJA to determine the differences in transfusion rate and PLOS.MethodsWe analyzed the data from 12,992 patients undergoing primary unilateral TJA: 6325 total knee arthroplasties (TKA) and 6667 total hip arthroplasties (THA). Patients were divided into two groups according to whether they received a drain postoperatively following TKA and THA. We extracted information for transfusion and PLOS from patients’ electronic health records and analyzed the data by logistic and linear regression analyses.ResultsThe transfusion rate and PLOS were 15.07% and 7.75 ± 3.61 days, respectively, in the drain group and 6.72% and 6.54 ± 3.32 days, respectively, in the no-drain group following TKA. The transfusion rate and PLOS were 20.53% and 7.00 ± 3.35 days, respectively, in the drain group and 13.57% and 6.07 ± 3.06 days, respectively, in the no-drain group following THA. After adjusting for the following variables: age, gender, body mass index, orthopedic diagnoses, hypertension, type 2 diabetes, coronary heart disease, chronic obstructive pulmonary disease, preoperative hemoglobin, albumin, analgesic use, anesthesia, American Society of Anesthesiologists class, tranexamic acid use, intraoperative bleeding, operative time, and tourniquet use (for TKA), drain use correlated significantly with a higher transfusion rate (risk ratio = 2.812, 95% confidence interval (CI) 2.224–3.554, P < 0.001 for TKA and risk ratio = 1.872, 95% CI 1.588–2.207, P < 0.001 for THA) and a longer PLOS (partial regression coefficient (B) = 1.099, 95% CI 0.879–1.318, P < 0.001, standard regression coefficient (B′) = 0.139 for TKA; B = 0.973, 95% CI 0.695–1.051, P < 0.001, and B′ = 0.115 for THA). Two groups showed no significant difference in wound complications.ConclusionsOur findings indicated that drain use was associated with a higher transfusion rate and a longer PLOS in patients undergoing routine primary TJA. The routine use of postoperative drainage is not recommended in primary unilateral TJA.

Operative Time Directly Correlates with Blood Loss and Need for Blood Transfusion in Total Joint Arthroplasty.

Allogeneic blood transfusion in patients undergoing total joint arthroplasty (TJA) has been shown to negatively affect patient outcomes. This study aimed to examine if there is a correlation between operative time and the need for allogeneic blood transfusions during TJA. We performed a retrospective review of 866 patients who underwent primary TJA during a one-year period at our institution. Logistic regression was performed to identify the association between operative time and need for allogeneic blood transfusion, controlling for other patient and surgical factors. Multiple linear regression analysis was also performed to see how the same factors affected CBL. Of the 866 cases, 13%(115) were simultaneous bilateral. 52%(449) of patients received preoperative autologous blood donation. The average operative time for unilateral and bilateral patients was 74.1±(33.9) and 132.6±(36.0) minutes, respectively. Average CBL for unilateral patients was 2120mL±(1208) and 4051mL±(1311) for bilateral cases. The average number of allogeneic transfusions was also higher within the bilateral group (0.49 vs 1.15 units). Multivariate analysis indicated that duration of surgery (odds ratio [OR]:1.35 per 15 minutes) and bilateral TJA (OR: 2.97) increase the risk of allogeneic blood transfusion, while patients having total knee arthroplasty are less likely to receive allogeneic blood transfusion (OR: 0.50). CBL also increased significantly with surgical duration (211.5 mL per 15 minutes). A subgroup analysis confirmed that there was a correlation between operative time and need for allogeneic transfusion following unilateral TJA. Expeditious surgery can minimize blood loss and subsequent need for blood transfusion and its associated adverse consequences. III.

Identifiable Risk Factors to Minimize Postoperative Urinary Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty

BackgroundPostoperative urinary retention (POUR) following total joint arthroplasty (TJA) presents a significant barrier to outpatient and early discharge TJA. This study examined the incidence and risk factors for acute POUR in a modern, evidence-based, outpatient, and early discharge TJA program. MethodsProspectively recorded data on 685 consecutive primary unilateral TJAs discharged the day of or day after surgery were retrospectively reviewed. POUR was diagnosed by a perioperative internal medicine specialist. Univariate analysis of potential predictors was performed, followed by binary logistic regression (BLR) testing of predictors with P ≤ .25. ResultsAfter exclusions for confounds, the final analysis sample consisted of 633 procedures. The overall incidence of POUR was 5.5% (3.9% for same day discharges). Male gender, history of urinary retention, use of rocuronium, use of glycopryrrolate, use of neostigmine, fentanyl spinals, and the absence of an indwelling urethral catheter were associated with acute POUR and met criteria for entry into multivariate BLR. Seventeen additional predictors, including kidney disease and outpatient surgery were unrelated to POUR. In the final BLR model (P = .001), male patients who received glycopyrrolate with neostigmine had a 34% probability of developing POUR, which declined to 2.8% in the absence of these risk factors. ConclusionDespite a relatively low incidence of 5.5%, avoidance of anticholinergics and cholinesterase inhibitors during anesthesia should be carefully considered in outpatient TJA, particularly in stand-alone ambulatory surgery centers.

Cotinine Testing Improves Smoking Cessation Before Total Joint Arthroplasty

BackgroundPatients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at an increased risk of perioperative complications. Serum cotinine testing is a sensitive and specific method to verify abstinence from smoking and may therefore improve a patient’s chance of smoking cessation. The primary purpose of this study was to assess whether cotinine testing improves the self-reported quit rate among smokers before TJA. MethodsOur hospital performs a high volume of TJAs and documents smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through an institutional total joint registry. As part of a retrospective analysis, this information was used to identify all self-reported smokers (regularly cigarette smoking within 1 year of TJA) who underwent unilateral TJA from 2007 to 2018. The cohort had a mean age of 66 years, 55% were female, and the mean body mass index was 31 kg/m2. Patients whose serum cotinine was obtained within 1 month before surgery were then separated from the cohort and compared to the smokers who did not undergo cotinine testing. ResultsOf the 28,758 primary TJAs identified, 8.8% (2514) were smokers. Serum cotinine testing was obtained on 103 of these patients. The abstinence rate (by means of self-reporting) before surgery significantly improved from 15.8% to 28.2% in the untested vs cotinine-tested groups, respectively (P = .005). Among all patients who underwent cotinine testing, 77% were negative (abstinent) and an additional 15% had cotinine levels between 3 and 8 ng/mL representing passive tobacco exposure. Among patients who stated they had quit smoking, 15% still had positive cotinine tests. ConclusionSmoking cessation remains a major challenge in contemporary TJA practices despite a concerted effort to help patients quit. Our findings suggest that cotinine testing significantly improves the self-reported quit rates of smokers before surgery and helps identify the 15% who falsely report abstinence to ensure appropriate counseling of inherent risks. Level of EvidenceTherapeutic level III.

Predicting Costs Exceeding Bundled Payment Targets for Total Joint Arthroplasty

BackgroundThe Center for Medicare and Medicaid Services has instituted bundled reimbursement models for total joint arthroplasty (TJA), which includes target prices for each procedure. Some patients exceed these targets; however, currently there are no tools to accurately predict this preoperatively. We hypothesized that a validated comorbidity index combined with patient demographics would adequately predict excess cost-of-care prior to hospitalization. MethodsTwo thousand eighty-four primary unilateral TJAs performed at a single tertiary center were retrospectively examined. Data were extracted from medical records and a predictive model was built from 30 comorbidities and 7 patient demographic factors (age, gender, race, body mass index, American Society of Anesthesiologists score, smoking status, and marital status). Following parameter selection, a final multivariable model was created, with a corresponding nomogram for interactive visualization of probability for excess cost. ResultsSix hundred twelve patients (29%) had cost-of-care exceeding the target price. The final model demonstrated adequate predictive discrimination for cost-of-care exceeding the target price (area under the receiver operator characteristic curve: 0.747). Factors associated with excess cost included age, gender, marital status, American Society of Anesthesiologists score, body mass index, and race, as well as 7 Elixhauser comorbidities (alcohol use, rheumatoid arthritis, diabetes, electrolyte disorders, neurodegenerative disorders, psychoses, and pulmonary circulatory disorders). ConclusionA novel patient model composed of a subset of validated comorbidities and demographic variables provides adequate discrimination in predicting excess cost within bundled payment models for TJA. This not only helps identify patients who would benefit from preoperative optimization, but also provides evidence for modification of future bundled reimbursement models to adjust for nonmodifiable risk factors.

Analysis of a large data set to identify predictors of blood transfusion in primary total hip and knee arthroplasty.

The aim of this study was to identify the predictors of need for allogenic blood transfusion (ALBT) in primary lower limb total joint arthroplasty (TJA). This study utilized a large dataset of 15,187 patients undergoing primary unilateral TJA. Risk factors and demographic information were extracted from the electronic health record. A predictive model was developed by both a random forest (RF) algorithm and logistic regression (LR). The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the accuracy of the two methods. The rate of ALBT was 18.9% in total. Patient-related factors associated with higher risk of an ALBT included female sex, American Society of Anesthesiologists (ASA) II, ASA III, and ASA IV. Surgery-related risk factors for ALBT were operative time, drain use, and amount of intraoperative blood loss. Higher preoperative hemoglobin and tranexamic acid use were associated with decreased risk for ALBT. The RF model had a better predictive accuracy (area under the curve [AUC] 0.84) than the LR model (AUC, 0.77; p < 0.001). The risk factors identified in the current study can provide specific, personalized perioperative ALBT risk assessment for a patient considering lower limb TJA. Furthermore, the predictive accuracy of the RF algorithm was significantly higher than that of LR, making it a potential tool for future personalized preoperative prediction of risk for perioperative ALBT.

Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System

BackgroundPrevious studies evaluating reasons for 30-day readmissions following total joint arthroplasty (TJA) may underestimate hospital-based utilization of healthcare resources during a patient's episode-of-care. We sought to identify common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary elective unilateral TJA. MethodsPatients from July 1, 2012 through June 30, 2015 having primary elective TJA and at least one 90-day postoperative ED-only visit and/or readmission for any reason were identified using the Kaiser Permanente Total Joint Replacement Registry. Chart reviews for ED visits/readmissions included 13 surgical and 11 medical reasons. The 2344 total hips and 5520 total knees were analyzed separately. ResultsIncidence of at least one ED visit following total hip arthroplasty (THA) was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%) and pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%). The incidence of at least one ED visit following total knee arthroplasty (TKA) was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%) and swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anesthesia (9.4%). ConclusionSwelling and pain related to the procedure were the most frequent reasons for 90-day ED visits after both THA and TKA. Readmissions were most commonly due to infection or unrelated procedures for THA and gastrointestinal or manipulation under anesthesia for TKA. Modifications to discharge protocols may help prevent or alleviate these issues, avoiding unnecessary hospital returns.

Are reinfusion drains safe to use with periarticular liposomal bupivacaine? An analysis of systemic bupivacaine toxicity.

BackgroundIntraoperative periarticular injection (PAI) with local anesthetic is an important component of multimodal pain control in total joint arthroplasty (TJA). A potential risk of this practice is serum anesthetic toxicity resulting from the autotransfusion of blood collected from a reinfusion drain. The purpose of this study is to evaluate the levels of bupivacaine in blood collected in an autotransfusion system after use of a PAI in TJA.MethodsIn this prospective study, each TJA patient had an identical PAI consisting of 20 cc of liposomal bupivacaine, 30 cc of 0.25% bupivacaine with epinephrine, and 10 cc of normal saline. An autologous reinfusion drain was utilized in all patients. At 2 and 5 hours postoperatively, blood was collected from the autotransfusion canister and sent to the laboratory to quantify bupivacaine levels. The sums of these levels were compared to the lowest reported serum bupivacaine dose associated with toxicity (1.1 mg/kg).ResultsEleven unilateral TJA patients were enrolled (6 total knee arthroplasties, 5 total hip arthroplasties). The average 2-hour serum bupivacaine level was 2.9 μg (range 0.8-5.6) while the average 5-hour serum bupivacaine level was 4.5 μg (range 0.4-10.0). The average sum of the 2-hour and 5-hour serum bupivacaine level was 5.6 μg (range 0.8-13.6). Each of the 11 patient samples were well below their minimum serum bupivacaine dose toxicity.ConclusionsUse of a reinfusion drain after PAI with liposomal bupivacaine in TJA appears safe, as bupivacaine levels in the autotransfused blood remains well below the reported minimum serum toxic dose.Level of EvidenceIV.

Patients with Staged Bilateral Total Joint Arthroplasty in Registries: Immortal Time Bias and Methodological Options.

In arthroplasty data, patients with staged bilateral total joint arthroplasty (TJA) pose a problem in statistical analysis. Subgroup analysis, in which patients with unilateral and bilateral TJA are studied separately, is sometimes considered an appropriate solution to the problem; we aim to show that this is not true because of immortal time bias. We reviewed patients who underwent staged (at any time) bilateral TJA. The logical fallacy leading to immortal time bias is explained through a simple artificial data example. The cumulative incidences of revision and death are computed by subgroup analysis and by landmark analysis based on hip replacement data from the Dutch Arthroplasty Register and on simulated data sets. For patients who underwent unilateral TJA, subgroup analysis can lead to an overestimate of the cumulative incidence of death and an underestimate of the cumulative incidence of revision. The reverse conclusion holds for patients who underwent staged bilateral TJA. Analysis of these patients can lead to an underestimate of the cumulative incidence of death and an overestimate of the cumulative incidence of revision. Immortal time bias can be prevented by using landmark analysis. When examining arthroplasty registry data, patients who underwent staged bilateral TJA should be analyzed with caution. An appropriate statistical method to address the research question should be selected.

Clinical validation of a body-fixed 3D accelerometer and algorithm for activity monitoring in orthopaedic patients

SummaryBackground/ObjectiveActivity is increasingly being recognized as a highly relevant parameter in all areas of healthcare for diagnosis, treatment, or outcome assessment, especially in orthopaedics where the movement apparatus is directly affected. Therefore, the aim of this study was to develop, describe, and clinically validate a generic activity-monitoring algorithm, satisfying a combination of three criteria. The algorithm must be able to identify, count, and time a large set of relevant daily activities. It must be validated for orthopaedic patients as well as healthy individuals, and the validation must be in a setting that mimics free-living conditions.MethodsUsing various technical solutions, such as a dual-axis approach, dynamic inclinometry (hip flexion), and semiautomatic calibration (gait speed), the algorithms were designed to count and time the following postures, transfers, and activities of daily living: resting/sitting, standing, walking, ascending and descending stairs, sit–stand transitions, and cycling. In addition, the number of steps per walking bout was determined. Validation was performed with healthy individuals and patients who had undergone unilateral total joint arthroplasty, representing a wide spectrum of functional capacity. Video observation was used as the gold standard to count and time activities in a validation protocol approaching free-living conditions.ResultsIn total 992 and 390 events (activities or postures) were recorded in the healthy group and patient group, respectively. The mean error varied between 0% and 2.8% for the healthy group and between 0% and 7.5% for the patient group. The error expressed in percentage of time varied between 2.0% and 3.0% for both groups.ConclusionActivity monitoring of orthopaedic patients by counting and timing a large set of relevant daily life events is feasible in a user- and patient-friendly way and at high clinical validity using a generic three-dimensional accelerometer and algorithms based on empirical and physical methods. The algorithms performed well for healthy individuals as well as patients recovering after total joint replacement in a challenging validation set-up. With such a simple and transparent method real-life activity parameters can be collected in orthopaedic practice for diagnostics, treatments, outcome assessment, or biofeedback.

A Comparison of Two Dosing Regimens of ASA Following Total Hip and Knee Arthroplasties

BackgroundThe purpose of this study was to compare short-term side effects of aspirin (ASA) 325 mg vs ASA 81 mg orally twice daily (PO BID) when used as thromboembolic prophylaxis following primary total joint arthroplasty. MethodsA 1-year prospective cohort study was performed on 643 primary unilateral total joint arthroplasty patients operated on by a single surgeon. Two hundred eighty-two patients were administered ASA 325 mg PO BID and 361 patients were administered ASA 81 mg PO BID for 1 month. A questionnaire assessing the side effects of ASA intake was administered 1 month postoperatively. ResultsThe overall rate of gastrointestinal side effects (GI upset and nausea) was 1.9%, but ASA 325 mg had a higher rate 9/282 (3.2%) than ASA 81 mg 3/361 (0.8%), P = .04. Overall GI bleeding was 0.9%, with 2/282 (0.7%) in the ASA 325 mg group, vs 4/361 (1.1%) in the ASA 81 mg group, P = .70. One patient in the ASA 81 mg group (0.3%) developed a deep vein thrombosis. No patient developed pulmonary embolism, periprosthetic joint infection, tinnitus, wheezing and/or shortness of breath, chest pain, or headaches. In the ASA 325 mg group, 9/282 (3.2%) discontinued ASA and in the ASA 81 mg group, 8/361 (2.2%) discontinued ASA, P = .47. Four patients in the ASA 325 group (1.4%) changed to ASA 81 mg. ConclusionASA 81 mg is associated with significantly less GI distress and nausea compared with ASA 325 mg. GI bleeding was equally prevalent between the 2 dosing regimens, so patients need to be informed of this risk regardless of the ASA dose.

The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program

ObjectivesThe purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients. MethodBetween April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6 = ‘high risk’, between 6 and 9 = ‘medium risk’, and >9 = ‘low risk’ for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility. Results70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility. ConclusionThe RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.

Are Preoperative Serologic Type and Screen Tests Necessary for Primary Total Joint Arthroplasty Patients in Specialty Surgical Hospitals?

BackgroundBlood loss during total joint arthroplasty (TJA) has been a major concern requiring routine preoperative patient type and screen (T&S); however, with the implementation of blood conserving therapy, a marked decrease for perioperative transfusions has been observed. Many TJAs are now being performed in T&S mandated specialty surgical hospitals (SSHs) that lack on-site blood banks; therefore, the purpose of our study was to determine whether T&S (1) is necessary in SSH for TJA patients and (2) identifies patient risk factors associated with perioperative blood transfusion in SSH. MethodsA retrospective study was conducted on 1034 consecutive primary TJAs performed between 2013 and 2014 at a 12-bed SSH who all received T&S. Patients were matched (1:1) to 964 inpatient TJA patients performed at a university hospital without routine T&S. Data on surgery type, patient demographics, hemoglobin and hematocrit results, and transfusion rates were collected. Multivariate logistic regression identified perioperative transfusion risk factors. ResultsOverall transfusion rates for the matched SSH (1.8% [17/964]) and university hospital populations (2.9% [28/964]) were similar (P = .13), with no emergent transfusions. SSH transfusion rates for simultaneous bilateral THA, simultaneous bilateral TKA, unilateral THA, and unilateral TKA were 21.1% (4/19), 3.1% (4/128), 2.7% (12/439), and 0.0% (0/448), respectively. Multivariate logistic regression identified unilateral THA (P ≤ .001), simultaneous bilateral TJA (P = .001), age (P = .05), and abnormal preoperative hemoglobin (P = .02) as significant transfusion risk factors at SSH. ConclusionDue to low transfusion rates and lack of emergency transfusions, we recommend routinely ordering T&S for bilateral THA but not for unilateral TJA patients, at SSHs.

Preoperative Anemia Is Associated with Increased Mortality Following Primary Unilateral Total Joint Arthroplasty

Background: Total joint arthroplasty is a commonly performed procedure for end-stage osteoarthritis. Preoperative anemia is a well-characterized and potentially modifiable risk factor for morbidity and mortality in non-cardiac surgery. This retrospective cohort study identified the prevalence of anemia in our total joint arthroplasty population and investigated if there was an association with all-cause mortality. Study Design and Methods: Using an electronic medical record, we examined all patients who underwent a primary unilateral total joint arthroplasty at Dartmouth-Hitchcock Medical Center from January 1, 2011 through July 1, 2015. Preoperative anemia thresholds were defined according to the World Health Organization as 12 mg/dl for women and 13 mg/dl for men. Kaplan-Meier survival analyses were performed to examine the relationship between preoperative anemia and all-cause mortality. Cox proportional hazards were calculated for various models adjusting for potential confounders. Results: 439 of the 3247 patients (13.5%) that underwent total joint arthroplasty met the preoperative definition for anemia. 48 patients (1.48%) died during 6470 patient years of follow up, generating an incidence rate of 7.4 deaths per 1000 patient years. The crude hazard ratio for death in anemic patients was 3.42 (95% CI 1.89, 6.82). In multiple models adjusting for various health related confounders, preoperative anemia was associated with a roughly two-fold increase risk of death compared to non-anemic patients. Conclusion: Preoperative anemia is prevalent in our population and it is associated with increased postoperative mortality in total joint arthroplasty patients, even when adjustments are made for significant co-morbidities.

Metabolic Syndrome and Deep Vein Thrombosis After Total Knee and Hip Arthroplasty

BackgroundMetabolic syndrome (MS), defined as obesity, hypertension, hyperglycemia, and dyslipidemia, is prevalent among patients undergoing total joint arthroplasty (TJA). MS has proven to promote a proinflammatory and prothrombotic state in patients. Venous thromboembolism is one of the major complications of TJA. The purpose of this retrospective study is to identify whether MS and its components increase the risk of deep vein thrombosis (DVT) after TJA. MethodsWe retrospectively reviewed 1553 patients undergoing primary unilateral TJA from 2007 to 2014. MS was diagnosed based on the World Health Organization criteria. All subjects received venography after operation to screen for DVT. Symptomatic DVT events after TJA were also recorded. Univariate analysis and multivariate logistic regression analysis were used to identify the association of MS and its components with postoperative DVT. ResultsThe prevalence of MS in patients undergoing TJA was 5.1% (n = 79). A total of 335 patients (21.6%) were diagnosed with DVT by venography. Seventy-eight patients (5.0%) developed symptomatic DVT. In the total knee arthroplasty group, MS and obesity were related to postoperative DVT. MS alone was found to be associated with symptomatic DVT. In the total hip arthroplasty group, MS increased the risk of symptomatic DVT. However, obesity, rather than MS, was associated with total DVT after total hip arthroplasty. ConclusionsMS was a significant risk factor for DVT after TJA. Strategies to minimize the adverse effect of MS should be considered for these patients.

Blood Conservation

Blood Conservation

Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty

A hospital-based computer system was used to compare the inpatient costs of performing bilateral simultaneous sequential, staged, and unilateral total hip and knee arthroplasties. Bilateral simultaneous sequential total knee arthroplasty was 36% less costly than 2 unilateral total knee arthroplasties. Bilateral simultaneous sequential total hip arthroplasty saved 25% over the costs of performing 2 unilateral hip arthroplasties. Prosthetic costs range between 28% and 43% of the total costs of hospitalization. There was a significant correlation between hospital length of stay, morbidity, and total costs, but no correlation with patient age and sex except in the unilateral knee patients. Bilateral simultaneous sequential joint arthroplasty can save more than $10,000 for each total knee patient and more than $8,000 for each total hip patient.