The Impact of Pre-Operative Healthcare Utilization on Complications,Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty

BackgroundIdentifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized.MethodsThis is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU.ResultsThe 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events.ConclusionPatients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU.Level of EvidenceLevel III.     

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.     

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.     

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BackgroundFalls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA.MethodsWe queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05.ResultsPatients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts.ConclusionFalls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation.Level of EvidenceIII.     

RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases

BackgroundChanges to Medicare’s Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA.MethodsWe identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C).ResultsReviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods.ConclusionRAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

The Impact of Mental Illness on Postoperative Adverse Outcomes After Outpatient Joint Surgery

BackgroundThe effect of pre-existing mental illness on outpatient surgical outcomes is not well characterized. The objective of this study was to evaluate the association between pre-existing mental illness diagnosis and postoperative complications after outpatient total knee (TKA) and total hip arthroplasty (THA) and 2) compare with inpatient total joint arthroplasty (TJA).MethodsThe Mariner Claims Database was used to capture patients undergoing outpatient TJA from 2010 to 2017. Patients were grouped into three categories: those with an existing history of anxiety and/or depression, those with severe mental illness, and those without history of mental illness. Additional subgroup analysis compared those with severe mental illness undergoing outpatient vs inpatient TJA. Outcomes were analyzed using multivariable logistic regression (P < .05).ResultsPatients undergoing outpatient TJA with prior history of anxiety and/or depression or severe mental illness had an increased risk of emergency department (ED) visits (TKA, P < .001; THA, P = .014) within 90 days compared with those without history of mental illness. Severe mental illness was also associated with increased risk of medical complications at 90 days (TKA, P < .001; THA, P = .006). When compared with those undergoing inpatient surgery, patients undergoing outpatient TKA with severe mental illness were at increased risk of periprosthetic infection (P = .005) and ED visit (P = .003) within 90 days of surgery.ConclusionAnxiety/depression and severe mental illness are associated with higher rates of ED visits after outpatient TJA. Patients with severe mental illness also experienced more adverse events, whereas those with anxiety and/or depression had similar rates compared with control. A higher rate of adverse outcomes was seen after TKA in patients with severe mental illness when surgery was performed in the outpatient setting vs those that had surgery as an inpatient.Level of EvidenceIII.     

How to Develop a Fair Revision Arthroplasty Bundle? Using Perioperative Complications and Readmissions to Investigate

BackgroundThe next frontier for value-based health care in total joint arthroplasty is revision surgery. Although the disparity in health care utilization between revision procedures compared with primary total hip and total knee arthroplasty (THA/TKA) procedures is recognized, no agreement regarding the risk adjustment necessary to make revision bundles fair to both payors and providers exists. The purpose of this study is to use the risk of perioperative complications and readmissions of patients undergoing revision THA/TKA to establish the foundations of a fair revision arthroplasty bundle.MethodsWe retrospectively evaluated a consecutive series of 484 aseptic THA/TKA revisions performed at our institution over a 12-month period and compared complications, length of stay, reoperations, and 90-day readmissions to a group of 802 consecutive patients undergoing primary THA/TKA.Results169 (34.9%) patients experienced major complications after revision THA/TKA compared with 176 (21.9%) patients undergoing primary THA/TKA (P < .001), (OR 1.91 CI 1.49-2.45, P < .001). Patients undergoing revision TKA were 3.64 times more likely to require hospitalization greater than 3 days (OR 2.59-5.12, CI 95%, P < .001), whereas patients undergoing revision THA were 4.46 times more likely to require hospitalization greater than 3 days (OR 2.89-6.87, CI 95%, P < .001). Revision patients were 3X more likely to have a 90-day readmission and 4X more likely to have a reoperation.ConclusionFor a revision bundle to be fair and widely adopted, either significant financial incentive must be instituted or the latitude given to exclude outliers from the final reconciliation. This must be adjusted to not disincentivize institutions from providing care for failed hip and knee arthroplasties.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.     

Same-Day Discharge Total Hip and Knee Arthroplasty: Trends,Complications, and Readmission Rates

BackgroundAlthough total hip arthroplasty (THA) and total knee arthroplasty (TKA) are transitioning to surgery centers, there remain limited data on trends, comorbidities, and complications in patients discharged the same day of surgery. In addition, many studies are limited to the Medicare population, excluding a large proportion of outpatient surgery patients.MethodsPrimary, elective THA/TKA cases between 2010 and 2017 were retrospectively identified using the PearlDiver All-Payer Database and separated based on surgery as well as same-day discharge (SDD) or non-SDD. Data were collected on demographics, rates, comorbidities, and complications. Multivariable logistic regression determined adjusted odds ratios (ORs) for 90-day complications requiring readmission for each group.ResultsIn total, 1,789,601 (68.8% TKA, 31.2% THA) patients were identified where 2.9% of TKAs and 2.2% of THAs were SDD. Annual SDD rates are increasing, with a 15.8% mean annual change for SDD-THA and 11.1% for SDD-TKA (P < .001). SDD patients were younger with fewer comorbidities (P < .001). Regression analysis showed an overall slightly higher OR of complications requiring readmission for SDD-TKA vs non-SDD-TKA (OR 1.14, 95% confidence interval [CI] 1.07-1.21, P < .001). There was no significant difference for SDD-THA vs non-SDD-THA (OR 1.03, 95% CI 0.94-1.13, P = .49). In univariate analysis, SDD-THA vs SDD-TKA had more mechanical complications (P < .001), but less pulmonary embolisms (P < .001). Regression analysis showed a slightly higher risk of complications for SDD-THA vs SDD-TKA (OR 1.19, 95% CI 0.99-1.44, P = .05).ConclusionThe prevalence of SDD is rising. SDD-THA is increasing more rapidly than SDD-TKA. SDD patients are generally younger with fewer comorbidities. SDD-TKA has slightly higher odds of complications requiring readmission than non-SDD-TKA. SDD-THA and SDD-TKA have different complication profiles.     

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis

BackgroundPatients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized.MethodsThe PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts.ResultsIn total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001).ConclusionCompared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA.Level of EvidenceLevel III.     

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BackgroundThis study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.MethodsA large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).ResultsOf patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.ConclusionPatients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.     

Early Discharge After Total Hip and Knee Arthroplasty—An Observational Cohort Study Evaluating Safety in 330,000 Patients

BackgroundThere has been considerable interest in recent years for early discharge after arthroplasty. We endeavored to evaluate the safety of same-day discharge given the rapid uptake of this practice approach.MethodsThis is a retrospective observational cohort study of the American College of Surgeons National Surgical Quality Improvement Program registry database. We included patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2015 and 2018. We categorized length of stay (LOS) as same-day discharge (LOS = 0 days), accelerated discharge (LOS = 1 day), and routine discharge (LOS = 2-3 days). For each LOS cohort, we determined the incidence of major complications within 30 days (surgical site infection [SSI], reoperation, readmission, deep vein thrombosis [DVT], and PE) and evaluated risk using multivariate logistic regression analysis if incidence was >1%. Patients undergoing THA and TKA were evaluated independently.ResultsThe final study cohort consisted of 333,212 patients, including 124,150 who underwent THA (37%) and 209,062 who had TKA (63%). In the THA same-day discharge cohort, the incidence of superficial SSI (0.2%), deep/organ space SSI (0.3%), DVT (0.2%), and PE (0.2%) was low. The risk of reoperation was comparable to routine discharge (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.09; P = .17) and readmission rate was significantly lower (OR, 0.60; 95% CI, 0.48-0.76; P < .001). The risk of reoperation and readmission was also lower in the accelerated discharge cohort compared to routine discharge. In the TKA same-day discharge cohort, the risk of superficial SSI (0.3%), deep/organ space SSI (0.3%), reoperation (0.8%), DVT (0.4%), and PE (0.5%) was low. The risk of readmission after same-day discharge was comparable to routine discharge (OR, 0.85; 95% CI, 0.71-1.01; P = .07). In the accelerated discharge cohort, there was a small reduction in readmission risk (OR, 0.87; 95% CI, 0.81-0.93; P < .001).ConclusionThis large, observational, real-world study suggests that same-day and accelerated discharge management is safe clinical practice for patients undergoing total joint arthroplasty, yielding a similar risk of major acute 30-day complications. Further clinical trials evaluating long-term major outcomes, including patient-reported outcomes and experiences, would offer further and definitive insight into this practice approach.     

The Efficacy of Telemedicine Versus In-Person Education for High-Risk Patients Undergoing Primary Total Joint Arthroplasty

BackgroundWhile multiple studies have demonstrated the positive impact of preoperative education on total joint arthroplasty (TJA) outcomes, the traditional method of conducting in-person individualized counseling or group education may limit access to these resources for a subset of the population. This study aimed to evaluate the use of preoperative telemedicine and in-person educational programs for primary TJA patients to determine if the utilization of telemedicine is inferior to in-person education in high-risk populations.MethodsA retrospective chart review of all “high-risk” patients undergoing primary unilateral TKA or THA by 1 of 10 board-certified surgeons at a single institution over 1 year was performed. Patients were prospectively classified as high-risk based on race/ethnicity, comorbidities, and socioeconomic and psychosocial factors. Demographics, comorbidities, and hospital outcomes were compared between patients receiving preoperative nurse navigator education via telemedicine versus those receiving face-to-face education.ResultsWhen comparing the interventions, telemedicine education was noninferior to face-to-face visits. No significant differences between postoperative length of stay, discharge home, 30-day emergency department return, or 30-day readmission rates were noted. Within the telemedicine group, patients who received video consultations were found to be 6 times more likely to be discharged home after surgery (odds ratio (OR): 5.95, 95% confidence interval (CI): 2.00 to 25.49; P = .004) and less likely to have a 30-day readmission than the phone consultations (OR: 0.36, 95% CI: 0.12 to 0.94: P = .050).ConclusionThis study demonstrates that telemedicine is not inferior to in-person preoperative education for patients undergoing unilateral TJA, although video-based consultation may improve outcomes over phone-only education.     

Participation in Sports and Physical Activities After Total Joint Arthroplasty

BackgroundQuality data on physical activity participation following total joint arthroplasty (TJA) are limited. The purpose of this study was to explore patient participation, outcomes, and limitations in sports/physical activities following TJA.MethodsPatients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a single institution from 2015 to 2020 were surveyed on sports/physical activity participation before and after TJA. Data were correlated with perioperative demographic and outcome scores. In total, 2,366 patients were surveyed: 788 (33.3%) underwent THA, 1,175 (49.7%) underwent TKA, and 403 (17.0%) underwent both THA/TKA.ResultsParticipation rates were 69.2, 61.5, and 61.3% at one year prior and 86.8, 81.5, and 81.6% at five years prior to THA, TKA, and THA/TKA, respectively. Participation rates were 73.1, 72.0, and 60.8% at mean 4.0 years postoperatively. Weekly time spent (P < .05) and exertion levels (P < .001) increased postoperatively for all three cohorts. For all three cohorts, the most common sports/activities were recreational walking, cycling, swimming, and golf, while intermediate- and high-impact activity participation decreased postoperatively. Independent predictors of postoperative sports/physical activity participation were younger age [THA (P < .001); TKA (P = .010)], lower body mass index [THA (P < .001); TKA (P < .001)], fewer comorbidities [THA (P < .001)], and higher postoperative Hip Injury and Osteoarthritis Outcome Score Junior[THA (P = .012)], Knee Injury and Osteoarthritis Outcome Score Junior[TKA (P = .004)], 12-Item Short Form Physical Component Score[THA (P < .001); TKA (P < .001); THA/TKA (P = .004)], and 12-Item Short Form Mental Component Score[TKA (P = .004)] scores. Activity restrictions were reported among 17.5, 20.9, and 25.1% of THA, TKA, and THA/TKA patients, respectively, and were more commonly self-imposed than surgeon-directed for all cohorts.ConclusionThough sports/physical activity participation may improve following TJA compared to one year preoperatively, participation is decreased compared to five years preoperatively, transitions to low-impact activities, and varies among subsets of patients.     

Revision Joint Arthroplasty and Renal Transplant: A Matched Control Cohort Study

BackgroundThere is little literature concerning clinical outcomes following revision joint arthroplasty in solid organ transplant recipients. The aims of this study are to (1) analyze postoperative outcomes and mortality following revision hip and knee arthroplasty in renal transplant recipients (RTRs) compared to non-RTRs and (2) characterize common indications and types of revision procedures among RTRs.MethodsA retrospective Medicare database review identified 1020 RTRs who underwent revision joint arthroplasty (359 revision total knee arthroplasty [TKA] and 661 revision total hip arthroplasty [THA]) from 2005 to 2014. RTRs were compared to their respective matched control groups of nontransplant revision arthroplasty patients for hospital length of stay, readmission, major medical complications, infections, septicemia, and mortality following revision.ResultsRenal transplantation was significantly associated with increased length of stay (6.12 ± 7.86 vs 4.33 ± 4.29, P < .001), septicemia (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.83-3.46; P < .001), and 1-year mortality (OR, 2.71; 95% CI, 1.51-4.53; P < .001) following revision TKA. Among revision THA patients, RTR status was associated with increased hospital readmission (OR, 1.23; 95% CI, 1.03-1.47; P = .023), septicemia (OR, 1.82; 95% CI, 1.41-2.34; P < .001), and 1-year mortality (OR, 2.65; 95% CI, 1.88-3.66; P < .001). The most frequent primary diagnoses associated with revision TKA and THA among RTRs were mechanical complications of prosthetic implant.ConclusionPrior renal transplantation among revision joint arthroplasty patients is associated with increased morbidity and mortality when compared to nontransplant recipients.     

Comparison of 90-Day Adverse Events Associated With Aspirin and Potent Anticoagulation Use for Venous Thromboembolism Prophylaxis: A Cohort Study of 72,288 Total Knee and 35,142 Total Hip Arthroplasty Patients

BackgroundWhile aspirin is acceptable for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty in most patients, more potent agents are used in patients considered higher risk for VTE. We evaluated the efficacy and safety of aspirin versus potent anticoagulation agents following total knee arthroplasty (TKA) and total hip arthroplasty (THA).MethodsA cohort study of 72,288 TKA and 35,142 THA from the Kaiser Permanente Total Joint Replacement Registry was performed (2009 to 2019). Identified medications were aspirin, factor Xa inhibitors, low-molecular-weight heparin (LMWH), and warfarin. A validated VTE risk score was assigned to each patient. Propensity score-weighted logistic regressions were used to evaluate 90-day VTEs. Noninferiority testing was performed with a margin of 1.25 using the upper bound (UB) of the 1-sided 95% CI.ResultsFor TKA, aspirin was not inferior to LMWH (odds ratio [OR] = 0.77, UB = 1.09) and warfarin (OR = 0.64, UB = 0.90); there was no evidence to support noninferiority of aspirin compared to factor Xa inhibitors. Findings were consistent for THA (LMWH: OR = 0.59, UB = 0.75; warfarin: OR = 0.69, UB = 0.89). TKA was considered higher risk for VTE, whereas aspirin use demonstrated noninferiority compared to warfarin (OR = 0.54, UB = 0.81), we lacked evidence of noninferiority when compared to LMWH and factor Xa inhibitors. We lacked evidence of noninferiority of aspirin versus any potent anticoagulation in higher-risk THA.ConclusionAspirin was found to be effective and safe for VTE prevention in primary total joint arthroplasty, including in patients considered higher risk for VTE.Level of EvidenceIII     

The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population

BackgroundPrior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population.MethodsA US integrated health system’s total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders.ResultsOf 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78).ConclusionWe observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities.Level of EvidenceLevel III.     

Use of a Smart-Phone Mobile Application is Associated With Improved Compliance and Reduced Length of Stay in Patients Undergoing Primary Total Joint Arthroplasty of the Hip and Knee

BackgroundPatient compliance with perioperative protocols is paramount to improving outcomes and reducing adverse events in total joint arthroplasty (TJA) of the hip and knee. Given the widespread use of smartphones, mobile applications (MAs) may present an opportunity to improve outcomes in TJA. We aim to determine whether the use of a mobile application platform improves compliance with standardized pre-operative protocols and outcomes in TJA.MethodsA non-randomized, prospective cohort study was conducted in adult patients undergoing primary elective TJA to determine whether the use of an MA with timed reminders starting 5 days pre-operatively, to perform a chlorhexidine gluconate (CHG) shower and oral hydration protocol improves compliance with these protocols. Outcome measures: compliance, length of stay (LOS), surgical site infection (SSI), 90-day readmission.ResultsApp-users had increased adherence to the hydration protocol (odds ratio [OR] = 3.17 [95% confidence interval {CI} = 1.42, 7.09: P = .003]). App-use was associated with shorter LOS (Median Interquartile ranges [IQR] 2.0 days [1.0, 2.0 days]) for App-users vs 2.0 days ([1.0, 3.0] for non-App users, P = .031), younger age, (63.3 vs 67.9 years, P = .0001), Caucasian race (OR = 3.32 [95% CI = 1.59, 6.94 P = .0009]) and male gender (48.2% vs 35.0%, P = .02). There was no difference in adherence to chlorhexidine gluconate (CHG), readmission, or surgical site infection (SSI) (2.2% App-users vs 2.9% non-App users; P = .74).ConclusionUse of a mobile application was associated with increased compliance with a hydration protocol and reduced LOS. App-users were more likely to be younger, male and Caucasian. These disparities may reflect inequity of access to the requisite technology and warrant further study.