Presenteeism and absenteeism before and after single-level lumbar spine surgery

Background ContextHealth can impact work performance through absenteeism, time spent away from work, and presenteeism, inhibited at-work performance. Low back pain is common and costly, both in terms of direct medical expenditures and indirect reduced work performance.PurposeSurgery for lumbar spinal pathology is an important part of treatment for patients who do not respond to nonsurgical management. While the indirect costs of return to work and absenteeism among employed patients undergoing lumbar spine surgery have been studied, little work has been done to quantify presenteeism before and after lumbar spine surgery.Study Design/SettingProspective cohort study at a single high-volume urban musculoskeletal specialty hospital.PATIENT SAMPLEPatients undergoing single-level lumbar spinal fusion and/or decompression surgery.Outcome MeasuresPresenteeism and absenteeism were measured using the World Health Organization's Health and Work Performance Questionnaire before surgery, as well as 6 weeks, 6 months, and 12 months after surgery.MethodsAverage presenteeism and absenteeism were evaluated at pre-surgical baseline and each follow-up timepoint. Monthly average time lost to presenteeism and absenteeism were calculated before surgery and 12 months after surgery. Study data were collected and managed using REDCap electronic data capture tools with support from Clinical and Translational Science Center grant, UL1TR002384. One author discloses royalties, private investments, consulting fees, speaking/teaching arrangements, travel, board of directorship, and scientific advisory board membership totaling >$300,000.ResultsWe enrolled 134 employed surgical patients, among whom 115 (86%) responded at 6 weeks, 105 (78%) responded at 6 months, and 115 (86%) responded at 12 months. Preoperatively, mean age was 56.4 years (median 57.5), and 41.0% were women; 68 (50.7%) had only decompressions, while 66 (49.3%) had fusions. Among respondents at each time point, 98%, 92%, and 92% were still employed, among whom 76%, 96%, and 96% had resumed working, respectively (median 29 days). Average at-work performance among working patients (who responded at each pair of timepoints) moved from 75.4 to 78.7 between baseline and 6 weeks, 71.8 to 85.9 between baseline and 6 months, and 73.0 to 88.1 between baseline and 12 months. Gains were concentrated among the 52.0% of patients whose at-work performance was declining (and low) leading up to surgery. Average absenteeism was relatively unmoved between baseline and each follow-up. Before surgery, the monthly average time lost to presenteeism and absenteeism was 19.8% and 18.9%, respectively; 12 months after surgery, these numbers were 9.7% and 16.0%; changes represent a mitigated loss of 13.0 percentage points of average monthly value.ConclusionsPresenteeism and absenteeism contributed roughly evenly to preoperative average monthly lost time. Although average changes in absenteeism and 6-week at-work performance were small, average changes in at-work performance at 6 and 12 months were significant. Cost-benefit analyses of lumbar spine surgery should therefore consider improved presenteeism, which appears to offset some of the direct and indirect costs of surgical treatment.     

Activity Impairment and Work Productivity Loss After Total Knee Arthroplasty: A Prospective Study

BackgroundTotal knee arthroplasty (TKA) is increasingly performed among working-aged individuals, highlighting the importance of work-related outcomes. Therefore, the aim is to examine the extent of both activity impairment outside work and work productivity (absenteeism, presenteeism, at-work productivity loss) at 6 and 24 months post-TKA surgery. Additionally, associated risk factors with these outcomes were evaluated.MethodsThis analysis included 183 patients <70 years undergoing TKA who completed questionnaires pre-operatively and during follow-up. Outcomes were derived from the Work Productivity and Activity Impairment questionnaire and included activity impairment, absenteeism (sick leave), presenteeism (reduced work performance), and at-work productivity loss (overall work productivity loss). All outcomes were scaled 0%-100%, with higher percentages indicating higher impairments. Covariates included age, gender, education, pain catastrophizing, pain, function, psychological distress, and knee-related and health-related quality of life. Linear and logistic regression was used to assess associations between covariates and Work Productivity and Activity Impairment scores at follow-up.ResultsAt 6 months, the mean activity impairment was 22.8% (standard deviation [SD] 23.5) dropping to 17.1% (23.1) by 24 months. Among workers, presenteeism was 18.4% (24.6) and at-work productivity loss was 20.8% (26.1). Both dropped significantly by 24 months to 14.2% (22.4) and 12.9% (20.9), respectively. Absenteeism levels were low at both time points. Pain catastrophizing was associated with all outcomes.ConclusionThis study showed that activity impairment and work productivity loss are common following TKA, decreased significantly over time, but still existed 2 years post-operatively. Those reporting high levels of pain catastrophizing may benefit from targeted rehabilitation guidance to reduce and possibly prevent activity impairment and work productivity loss.     

Complication Rates and the Benefits of Neuraxial Anesthesia in the Patient With High Comorbidity Burden Undergoing Primary Total Joint Arthroplasty

BackgroundThe American Society of Anesthesiologists physical status classification 4 (ASA PS 4) comprises patients with “severe systemic disease that is a constant threat to life.” The purpose of this study is to conduct a retrospective analysis to report the rate of complications in the ASA PS 4 patients who undergo elective total joint arthroplasty (TJA). In addition, we report whether neuraxial anesthesia is associated with improved outcomes compared to general anesthesia in these patients.MethodsThe American College of Surgeons National Surgical Quality Improvement Program registry was used to extract patient records. The study population included patients aged ≥18 years who underwent TJA from 2014 to 2016 and who were classified as ASA PS 4. To measure differences in outcomes and patient characteristics, we used chi-squared tests. Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported for all covariates. A P value of <.01 was selected.ResultsAmong the patients who were ASA PS 4, 58 (1.4%) experienced 30-day mortality, 349 (8.2%) experienced 30-day readmission, 271 (6.3%) had a postoperative complication, and 504 (11.8%) required a transfusion. Those receiving neuraxial anesthesia compared to general anesthesia had lower odds of 30-day mortality (OR, 0.24; 95% CI, 0.12-0.49; P = .0001) and lower odds of perioperative transfusion (OR, 0.53; 95% CI 0.45-0.65; P < .0001).ConclusionThe elevated risks for ASA PS 4 patients undergoing TJA may be too high to justify surgery. Neuraxial anesthesia is a reasonable alternative to general anesthesia if pursuing TJA in patients with a very high comorbidity burden.     

Patients with axial spondyloarthritis report significant differences between men and women and high impact of the disease: Large websurvey analysis

ObjectiveIn axial spondyloarthritis (axSpA), mounting evidence shows female patients to experience a higher disease burden. These differences appear to be particularly large in South America. One explanation could be inequity in treatment access between men and women. The objective was to evaluate gender differences in disease burden and work participation, and the potential influence of treatment, in Latin American patients.MethodsA cross sectional online survey among axSpA patients, collecting disease characteristics, treatment, disease burden (BASDAI, BASFI, ASAS Health Index) and work participation (WPAI). Associations between gender and disease burden or work participation were assessed through regression analyses, correcting for treatment.ResultsAxSpA was reported by 472 participants (63% women) and disease activity (BASDAI ≥ 4: 83%), ASASHI (≥ moderately impaired: 91%) and work disability (absenteeism: 41%; presenteeism 82%) were high. Biological use was very low (20%), while 34% used opiates. Females had significantly higher BASDAI, ASAS HI, work absenteeism and presenteeism, although were less likely to receive biologics (26% versus 16%, P < 0.01). Gender differences disappeared after correction for treatment.ConclusionsThis web survey in Latin American axSpA patients shows a high disease burden and work impairment. The use of biologics is low, while the use of opiates was alarmingly high. Women used significantly less biologics despite reporting a worse disease state and work disability, which could be due to treatment inequity.     

Frequency,Cost, and Clinical Significance of Incidental Findings on Preoperative Planning Images for Computer-Assisted Total Joint Arthroplasty

BackgroundThe frequency of incidental findings with computer-assisted total joint arthroplasty (CA TJA) preoperative imaging and their clinical significance are currently unknown.MethodsWe reviewed 573 patients who underwent primary CA TJA requiring planning imaging. Incidental findings were defined as reported findings excluding those related to the planned arthroplasty. Secondary outcomes were additional tests or a delay in surgery. Associated charges were obtained from our institution’s website. Charge and incidence data were combined with TJA volumes obtained from the 2016 National Inpatient Sample to model costs to the healthcare system.ResultsOverall, 262 patients (45.7%) had at least 1 incidental finding, 144 patients (25.1%) had 2, and 65 (11.3%) had 3. The most common finding types were musculoskeletal (MSK, 67.7%), digestive (19.5%), cardiovascular (4.9%), and reproductive (4.7%). Also, 9.3% of patients had at least 1 non-MSK incidental finding. Both MSK and non-MSK incidental findings were more common with total hip arthroplasty compared to total knee arthroplasty (67.9% vs 42.2%, P < .0001, and 15.4% vs 8.3%, P < .05, respectively). Further testing was required in 6 cases (1.0%); 1 case required delay in surgery (0.2%). Using the 2016 volume of TJA procedures and assuming a 10%, 15%, and 25%, utilization rate of image-based CA TJA, the annual cost of additional testing was $2.7 million (95% confidence interval, $1.1-$6.3 million), $4.1 million ($1.6-$9.5 million), and $6.9 million (95% confidence interval, $2.7-$15.8 million), respectively.ConclusionIncidental findings are relatively common on planning images. Stakeholders should be aware of the hidden costs of incidental findings given the increasing popularity of image-based CA TJA.     

Are Patient-Reported Drug Allergies Associated With Prosthetic Joint Infections and Functional Outcomes Following Total Hip and Knee Arthroplasty?

BackgroundThe purpose of this study is to determine if the number and types of patient-reported drug allergies are associated with prosthetic joint infection (PJI) and functional outcomes following total joint arthroplasty (TJA).MethodsThis is a retrospective review of all patients who underwent a primary, elective total hip (THA) or knee arthroplasty (TKA) over a 10-year period at a single academic institution. Demographic, clinical information, and number and type of patient-reported drug allergy was collected. Univariate and multivariate logistic regressions were performed to identify risk factors for PJI and risk of PJI based on number of allergies. Univariate analysis was also performed to identify if the number of patient-reported allergies affected functional outcome scores.ResultsOf 31,109 patients analyzed, there were 941 (3%) revisions for infection (491 knees and 450 hips). At least one allergy was reported by 16,435 (52.8%) patients, with a mean of 1.2 ± 1.9. Those who underwent revision for infection had a significantly higher number of reported allergies (1.68 ± 1.9 vs 1.23 ± 1.9, P < .0005, 95% confidence interval ?0.58 to 0.33). On univariate regression the number of allergies independently predicted revision TJA for infection (P < .0001) as did age, gender, body mass index, and smoking status. On multivariate regression for each additional patient-reported allergy, risk of PJI increased by 1.11 times (95% confidence interval 1.07-1.14, P < .0001). Number of patient-reported allergies did not predict 3-month or 1-year functional outcome scores.ConclusionPatients with a higher number of reported allergies may be at increased risk of PJI following TJA.Level of EvidencePrognostic Level II.     

Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundPersistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.ResultsSSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).ConclusionciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.     

The Changing Characteristics of Arthroplasty Patients: A Retrospective Cohort Study

BackgroundTotal joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017.MethodsA retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included.ResultsOverall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m², P < .0001) and total knee arthroplasty (TKA; 32.0-3.1 kg/m², P < .0001) patients. THA patients were significantly younger in more recent years (68.0-66.8 years old, P = .0026); this trend was not observed among TKA patients. Over the study period, a significantly higher proportion of patients were American Society of Anesthesiologists class III/IV for THA (50.5%-72.3%) and TKA (57.5%-80.7%) (P < .00001). Prevalence of common comorbidities did not change significantly.ConclusionThe key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future.Level of EvidenceLevel III, retrospective cohort study.     

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BackgroundResearch has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.MethodsTJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.ResultsAbout 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission.ConclusionScreening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.     

Resilience and Depression Influence Clinical Outcomes Following Primary Total Joint Arthroplasty

BackgroundResilience and depression may impact clinical outcomes following primary total joint arthroplasty (TJA). This study aimed to quantify baseline resilience and depression prevalence in patients undergoing primary TJA and evaluate their influence on patient-reported clinical outcomes.MethodsWe prospectively enrolled 98 patients undergoing primary TJA. Exclusion criteria included patients under 18 years of age, undergoing surgery for fracture, or who underwent additional surgery during the study period. Patients completed the Brief Resilience Scale to measure resilience, Patient Health Questionnaire-9 to measure depression, and Patient-Reported Outcomes Measurement Information System-10 to measure global physical and mental health preoperatively and 1 year postoperatively.ResultsPreoperatively, 22% and 15% of patients demonstrated major and mild depression, respectively. High resilience was identified in 34% of patients, normal resilience in 55%, and low resilience in 11%. Preoperative depression correlated with lower resilience, global physical health, and global mental health scores preoperatively as well as at 1 year after surgery (P < .001). Higher levels of preoperative resilience correlated with higher global physical and mental health scores preoperatively and at 1 year postoperatively (P < .001).ConclusionDepression symptoms are common among patients undergoing primary TJA and are associated with worse patient-reported outcomes. Patients with higher levels of resilience have higher global physical and mental health scores before and after TJA. Psychological traits and depression impact clinical outcomes following TJA.     

Insulin-Dependent Diabetic Patients are at Increased Risk of Postoperative Hyperglycemia When Undergoing Total Joint Arthroplasty

BackgroundDiabetic patients are at an increased risk of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The relationship between insulin-dependence and PJI has not been investigated. We aimed at evaluating whether insulin-dependent diabetes mellitus (IDDM) patients were more susceptible to postoperative hyperglycemia and PJI than their non–insulin-dependent diabetes mellitus (NIDDM) counterparts.MethodsA retrospective review was conducted of diabetic patients undergoing TJA (hip or knee) from January 2011 to December 2016. Preoperative hemoglobin A1c (A1c) and postoperative glucose measurements were observed. Patients were stratified as IDDM or NIDDM. The A1c values that predicted hyperglycemia >200 mg/dL for each group were calculated. Primary end point was postoperative hyperglycemia >200 mg/dL and secondary end point was PJI.ResultsThere were 773 patients meeting inclusion criteria. The IDDM cohort had a higher preoperative A1c (6.97% vs 6.28%, P < .0001) and postoperative glucose (235.2 vs 163.5, P < .0001). IDDM patients were more likely to have postoperative hyperglycemia (63.84% vs 20.83%, P < .0001; odds ratio, 5.2; 95% confidence interval, 3.66-7.4). Overall, an A1c of >7.45% predicted postoperative hyperglycemia >200 mg/mL (odds ratio, 6.94; 95% confidence interval, 4.32-11.45). When separating our 2 cohorts, an A1c of >6.59% in IDDM, and >6.60% in NIDDM, was associated with an increased risk of postoperative hyperglycemia (P < .0001). PJI was similar between the 2 cohorts (2.52% vs 2.38%, P = .9034).ConclusionIDDM patients undergoing TJA are 5.2 times more likely to have postoperative hyperglycemia >200 mg/dL than their NIDDM counterparts, although increased risk of PJI was not found in this study. Despite the higher A1c and postoperative hyperglycemia in IDDM patients, there was found to be no clinical difference between A1c cutoff values for postoperative hyperglycemia between IDDM and NIDDM patients.     

Insulin Dependence Increases the Risk of Complications and Death in Total Joint Arthroplasty: A Systematic Review and Meta‐(Regression) Analysis

ObjectivesTo investigate the proportion of insulin‐dependent diabetes mellitus (IDDM) patients among diabetic patients undergoing total joint arthroplasty (TJA) and whether insulin dependence is associated with postoperative complications.MethodsA systematic literature search was performed in EMBASE, PubMed, Ovid, Medline, the Cochrane Library, Web of Science, the China Science and Technology Journal Database, and China National Knowledge Infrastructure from the inception dates to 10 September 2019. Observational studies reporting adverse events with IDDM following TJA were included. Primary outcomes were cardiovascular complications, pulmonary complications, kidney complications, wound complications, infection, and other complications within 30 days of surgery. Secondary outcomes were the proportion of IDDM patients among diabetic patients undergoing TJA and its time trend.ResultsA total of 19 studies involving 85,689 participants were included. Among patients undergoing TJA, 26% of diabetic patients had IDDM. Compared with non‐insulin‐dependent diabetes (NIDDM), the incidences of cardiac arrest (risk ratio [RR], 2.346; 95% confidence interval [CI], 1.553 to 3.546), renal failure (relative risk [RR], 2.758; 95% CI, 1.830 to 4.156), deep incisional surgical site infection (RR, 1.968; 95% CI, 1.107 to 3.533), wound dehiscence (RR, 2.209; 95% CI, 1.830 to 4.156), and death (RR, 2.292; 95% CI, 1.568 to 3.349) were all significantly increased in IDDM. A significant time trend was witnessed for the prevalence of IDDM (P = 0.014). There was no statistical significance for organ/space surgical site infection, thrombotic events (deep venous thrombosis/ pulmonary embolism), and revision rates.ConclusionInsulin‐dependent diabetes is an independent high‐risk factor for increased adverse outcomes relative to NIDDM, suggesting that hierarchical and optimal blood glucose management may contribute to reducing the adverse complications after surgery for these patients. In addition, because the risk of sepsis, deep wound infection, organ/space surgical site infection, urinary tract infection, renal insufficiency, and renal failure significantly increase after TJA in IDDM patients, more active postoperative antimicrobial prophylaxis may be needed on the premise of protecting renal function.     

Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing,Anxiety, or Depression

BackgroundThe relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.MethodsA prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.ResultsWe recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).ConclusionTJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty.     

Rates and Outcomes of Periprosthetic Joint Infection in Persons Who Inject Drugs

BackgroundThe risk of periprosthetic joint infection (PJI) is higher in persons who inject drugs (PWID) after total joint arthroplasty (TJA), though reported rates vary widely. This study was designed to assess outcomes of TJA in PWID and to describe factors associated with improved PJI outcomes among PWID.MethodsA retrospective matched cohort study was performed using a 1:4 match among those with and those without a history of injection drug use (IDU) undergoing TJA. Demographic, surgical, and outcome variables were compared in multivariate logistic regressions to determine PJI predictors. Kaplan-Meier analyses were constructed to characterize the difference in survival of patients who did not have PJI or undergo joint explantation between PWID and the matching cohort.ResultsPWID had a 9-fold increased risk of PJI compared to the matched cohort (odds ratio 9.605, 95% CI 2.781-33.175, P < .001). Ten of 17 PWID whose last use was within 6 months (active use) of primary TJA had a PJI, while 7 of 41 PWID who did not have active use developed a PJI. Of PWID with PJI, treatment failure was seen in 15 of 17, while in patients who did not have an IDU history, 5 of 8 with PJI had treatment failure.ConclusionIDU is a significant risk factor for PJI following TJA. Future work investigating the effect of a multidisciplinary support team to assist in cessation of IDU and to provide social support may improve outcomes and reduce morbidity in this vulnerable population.     

Psychological Distress Independently Predicts Prolonged Hospitalization After Primary Total Hip and Knee Arthroplasty

BackgroundThe purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA).MethodsA retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed.ResultsThe prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P < .0001) and more likely to have depression (P < .0001), lower educational attainment (P < .0001), smoke tobacco (P = .003), be Hispanic/Latino (P = .001), live alone (P = .001), and have higher rates of nonprimary osteoarthritis (P < .0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P = .049 and .006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P = .913 and .782 for THA and TKA, respectively), emergency room visits (P = .467 and .355 for THA and TKA respectively), or readmissions (P = .118 and .334 for THA and TKA, respectively).ConclusionPsychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted.     

A Validated Pre-operative Risk Prediction Tool for Extended Inpatient Length of Stay Following Primary Total Hip or Knee Arthroplasty

BackgroundAs value-based reimbursement models mature, understanding the potential trade-off between inpatient lengths of stay and complications or need for costly postacute care becomes more pressing. Understanding and predicting a patient’s expected baseline length of stay may help providers understand how best to decide optimal discharge timing for high-risk total joint arthroplasty (TJA) patients.MethodsA retrospective review was conducted of 37,406 primary total hip (17,134, 46%) and knee (20,272, 54%) arthroplasties performed at two high-volume, geographically diverse, tertiary health systems during the study period. Patients were stratified by 3 binary outcomes for extended inpatient length of stay: 72 + hours (29%), 4 + days (11%), or 5 + days (5%). The predictive ability of over 50 sociodemographic/comorbidity variables was tested. Multivariable logistic regression models were created using institution #1 (derivation), with accuracy tested using the cohort from institution #2 (validation).ResultsDuring the study period, patients underwent an extended length of stay with a decreasing frequency over time, with privately insured patients having a significantly shorter length of stay relative to those with Medicare (1.9 versus 2.3 days, P < .0001). Extended stay patients also had significantly higher 90-day readmission rates (P < .0001), even when excluding those discharged to postacute care (P < .01). Multivariable logistic regression models created from the training cohort demonstrated excellent accuracy (area under the curve (AUC): 0.755, 0.783, 0.810) and performed well under external validation (AUC: 0.719, 0.743, 0.763). Many important variables were common to all 3 models, including age, sex, American Society of Anesthesiologists (ASA) score, body mass index, marital status, bilateral case, insurance type, and 13 comorbidities.DiscussionAn online, freely available, preoperative clinical decision tool accurately predicts risk of extended inpatient length of stay after TJA. Many risk factors are potentially modifiable, and these validated tools may help guide clinicians in preoperative patient counseling, medical optimization, and understanding optimal discharge timing.     

Online Crowdsourcing Survey of United States Population Preferences and Perceptions Regarding Outpatient Hip and Knee Arthroplasty

BackgroundOutpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty.MethodsA closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed.ResultsIn total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA.ConclusionDespite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities.     

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons

BackgroundWe sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT).MethodsA single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019.ResultsIn total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001).ConclusionFor both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training.Level III EvidenceRetrospective Cohort Study.     

Evidence of Pent-Up Demand for Total Hip and Total Knee Arthroplasty at Age 65

Background

Despite efforts to curtail the economic burden of total joint arthroplasty (TJA), utilization of these successful procedures continues to increase. Previous studies have provided evidence for pent-up demand (delaying necessary medical care until financially feasible) in health care as insurance status changes. We sought to determine whether evidence exists for pent-up demand in the TJA population when patients become eligible for Medicare enrollment.