Dabigatran Etexilate Prevents Venous Thromboembolism After Total Knee Arthroplasty in Japanese Patients With a Safety Profile Comparable to Placebo

We assessed the efficacy, safety, and dose-response of dabigatran etexilate (DAB) in preventing venous thromboembolism (VTE) in Japanese patients undergoing total knee arthroplasty (TKA). Five hundred twelve patients received DAB (110, 150, or 220 mg) or placebo once daily for 11 to 14 days, starting the day after surgery. The primary efficacy end point was the incidence of total VTE and all-cause mortality; the primary safety end point was incidence of major, clinically relevant, and minor bleeding events. Total VTE and all-cause mortality were lower in patients receiving DAB (39.6%, 32.7%, and 24.0%) than placebo (56.4%). There was no difference in the incidence of major bleeding between the DAB and placebo groups. Overall, DAB reduced the incidence of VTE in Japanese patients undergoing TKA, with a comparable safety profile vs placebo.     

Safety and Efficacy of Rivaroxaban in Primary Total Hip and Knee Arthroplasty

BackgroundAn optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin.MethodsA large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin.ResultsAfter accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036).ConclusionRivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.     

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients

BackgroundThis study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs).MethodsBetween July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index.ResultsBefore surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3).ConclusionImprovement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.     

Chronic Thrombocytopenia and In-Hospital Outcomes After Primary Total Hip and Knee Arthroplasty

BackgroundThere is a lack of data on the influence of chronic thrombocytopenia (cTCP) on clinical outcomes following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Limited studies mainly focused on postoperative heparin-induced TCP from single centers with small sample sizes. This study aims to describe the characteristics, trend, and outcomes of cTCP in patients undergoing THA and TKA from a nationally reprehensive perspective.MethodsWe identified THA and TKA patients with and without cTCP from the 2005 to 2015 Nationwide Inpatient Sample. Annual percent changes were calculated to reflect cTCP trends. Multivariable regression and propensity score analyses were conducted to investigate the association of cTCP and mortality, preoperative complications, cost as well as length of stay.ResultsIn total, 578,278 and 1,237,331 patients underwent primary THA and TKA, respectively. Proportion of cTCP annually increased by 6.95% in THA and 6.66% in TKA. Patients with cTCP were associated with higher risk of medical (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.89-2.11) and surgical complications (OR 2.72, 95% CI 2.55-2.90) in THA, and higher risk of mortality (OR 1.68, 95% CI 1.22-2.31), medical (OR 1.94, 95% CI 1.85-2.03) and surgical complications (OR 2.55, 95% CI 2.38-2.73) in TKA. Additionally, higher cost and longer length of stay were observed in patients with cTCP for both surgical procedures.ConclusionPatients with cTCP had higher risk of mortality for TKA, more perioperative complications for both TKA and THA. Further studies are warranted to improve the preoperative management and to prevent worse outcomes associated with cTCP.     

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

BackgroundVenous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA).MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference.ResultsOverall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05).ConclusionApproximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed.Level of EvidenceIII.     

The Efficacy of Combined Use of Rivaroxaban and Tranexamic Acid on Blood Conservation in Minimally Invasive Total Knee Arthroplasty a Double-Blind Randomized,Controlled Trial

Background

Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.

Predictors of Chronic Pain in Elderly Patients Undergoing Total Knee and Hip Arthroplasty: A Prospective Observational Study

BackgroundChronic postsurgical pain (CPSP) after total knee arthroplasty and total hip arthroplasty (TKA and THA) is an important clinical problem in which many factors play a role. The risk factors for CPSP in elderly individuals are currently unknown. Therefore, our aim was to predict the risk factors for CPSP after TKA and THA and to provide help regarding early screening and interventions for elderly individuals at risk.MethodsIn this prospective observational study, we collected and analyzed 177 TKA patients and 80 THA patients. Based on pain results at the 3-month follow-up, they were divided into the no chronic postsurgical pain and CPSP groups, respectively. The preoperative baseline conditions, including pain intensity (Numerical Rating Scale) and sleep quality (Pittsburgh Sleep Quality Index), as well as intraoperative and postoperative factors, were compared. Factors with P < .05 were included in binary regression analyses to establish prediction models for CPSP after TKA and THA.ResultsThe prevalence of CPSP was 20.9% after TKA and 7.5% after THA. The preoperative sleep disorders were an independent risk factor of CPSP after TKA, but no risk factors of CPSP after THA were identified.ConclusionThis study indicated that the prevalence of CPSP after TKA was significantly higher than after THA, and that preoperative sleep disorders were an independent risk factor for CPSP after TKA, which may aid clinicians in screening people at risk for CPSP for primary prevention.     

Alcohol Withdrawal Is Associated With Worse Outcomes in Patients Undergoing Primary Total Knee or Total Hip Arthroplasty

BackgroundAlcohol withdrawal (AW) syndrome is an independent risk factor for postoperative complications. This study aims to evaluate the influence of AW on perioperative outcomes in patients who underwent primary total knee (TKA) or total hip arthroplasty (THA).MethodsWe used the National Inpatient Sample database to identify patients undergoing TKA/THA from 2003 to 2014. The primary exposure of interest was AW. Multivariable adjusted models were used to evaluate the association of AW with in-hospital medical complications, surgical complications, mortality, cost, and length of stay (LOS) in patients undergoing TKA/THA.ResultsThere were 2,971,539 adult hospitalizations for THAs and 6,367,713 hospitalizations for TKAs included in the present study, among which 0.14% of AW for THA patients and 0.10% of AW for TKA patients. Multivariable adjustment analysis suggested that AW was associated with an increased risk of medical complications (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.79-2.42, P < .0001), surgical complications (OR 1.75, 95% CI 1.51-2.03, P < .0001), and had 4.79 times increase of in-hospital mortality, 26% increase of total cost, and 53% increase of LOS in THA procedures. For TKA procedures, AW was also associated with increased risk of medical complications (OR 3.14, 95% CI 2.78-3.56, P < .0001), surgical complications (OR 2.07, 95% CI 1.82-2.34, P < .0001) and 4.24 times increase of in-hospital mortality, 29% increase of total cost, and 58% increase of LOS after multivariable adjustment.ConclusionAW is associated with increased risk of in-hospital mortality, medical and surgical complications. Proactive surveillance and management of AW may be important in improving outcomes in patients who underwent THA and TKA procedure.     

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty

Background

There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA.

Risk of Total Knee and Hip Arthroplasty in Patients With Rheumatoid Arthritis: A 12-Year Retrospective Cohort Study of 65,898 Patients

BackgroundRheumatoid arthritis (RA) is an inflammatory disease that causes the destruction of soft tissues and cartilage around joints. Owing to the widespread use of potent disease-modifying antirheumatic drugs, the need for total knee and hip arthroplasties (TKA and THA) has been reduced in patients with RA. However, the current association between RA and either THA or TKA has not been demonstrated in large-scale epidemiological studies.MethodsWe conducted a large-scale retrospective cohort study of patients diagnosed with RA during a 12-year period (2000-2012) in Taiwan. We recruited 32,949 patients with RA and 32,949 individually propensity score-matched non-RA controls.ResultsAfter adjusting for confounding factors, we found that the risk of THA or TKA was 4.02 times higher in patients with RA than in those without RA (95% confidence interval [CI], 3.77-4.52). The risk of THA or TKA was highest in patients with RA younger than 40 years (adjusted hazard ratio, 43.18; 95% CI, 16.01-116.47). Compared with non-RA patients, patients with RA were 4.82 times more likely to undergo THA (95% CI, 3.84-6.04), 3.85 times more likely to undergo TKA (95% CI, 3.48-4.25), and 19.06 times more likely to undergo both THA and TKA (95% CI, 8.90-40.80).ConclusionThese findings document a 4.02-fold greater long-term risk of undergoing THA or TKA in RA patients relative to non-RA patients in Taiwan.     

Does Age Influence Patient-Reported Outcomes in Unilateral Primary Total Hip and Knee Arthroplasty?

BackgroundTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are used to treat patients with end-stage arthritis. Previous studies have not demonstrated a consistent relationship between age and patient-reported outcomes. The purpose of this study is to assess the impact of age on patient-reported outcomes after unilateral primary THA or TKA.MethodsA retrospective review of available data in Alberta Bone and Joint Health Institute (ABJHI) Data Repository was performed. We identified 53,498 unilateral primary THA and TKA between April 2011 and 2017. Patients were divided by age into 3 categories: <55, 55-70, and >70. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQoL 5-dimension (EQ-5D) Canada scores were obtained at presurgery, 3 and 12 months postoperatively.ResultsFor TKA, younger patients had larger improvements in WOMAC scores at 3 and 12 months (P = <.001-.033), and in EQ-5D scores at 3 months (P < .001). When adjusted, patients <55 had lower WOMAC and EQ-5D scores at 3 months postoperatively compared to those 55-70 or >70 (all P < .01). Outcomes at 12 months did not differ between age-groups.For THA, younger patients had larger improvements in WOMAC at 3 months (P = .03). When adjusted, patients <55 had higher WOMAC scores at 12 months postoperatively compared to those 55-70 or >70, and higher EQ-5D scores compared to those 55-70 (all P < .05).ConclusionWhile a multitude of factors go in to quantifying successful THA or TKA, this study suggests that patient age should not be a deterrent when considering the impact of age on patient-reported outcomes.     

Early Emergency Department Visits Following Primary Hip and Knee Arthroplasty

BackgroundPostoperative emergency department (ED) utilization remains an understudied aspect of total joint arthroplasty (TJA). The purpose of this study is to characterize 30-day ED visits following TJA.MethodsWe reviewed 4061 primary unilateral total hip and knee arthroplasty cases performed at our hospital from 2013 to 2017. The primary outcome was presentation to our institution’s ED within 30 days of surgery. Chief complaints and their association to the TJA encounter, as well as readmissions and reoperations, were recorded. One-to-three propensity score matched analysis was used to identify index admission variables associated with early ED visits.ResultsThere were 253 recorded ED visits within 30 days of TJA (218 cases, 5.4%). Nearly 60% of ED visits were directly related to the TJA encounter. The remainder were medically related, most commonly for gastrointestinal complaints. The most common TJA-related complaints were surgical limb pain (28%), wound concerns (20%), and swelling (20%). These complaints comprised two-thirds of TJA-related ED visits, though accounted for only 19.4% and 9.5% of readmissions and reoperations observed in this cohort, respectively. Perioperative transfusion, length of stay, primary insurer, and discharge disposition were not associated with an ED visit.ConclusionED visits within 30 days of TJA were common (5.4%). Most visits related to the index procedure were due to surgical limb pain, wound concerns, and swelling. These complaints accounted for a minority of readmissions and reoperations. This study suggests that perioperative strategies addressing common postoperative concerns are warranted to mitigate acute care use after TJA.     

Are Functional Outcomes of a Total Hip Arthroplasty Predictive of a Contralateral Total Hip Arthroplasty: A Retrospective Cohort Study

BackgroundCurrent literature suggests that 8%-35% of patients undergoing total hip arthroplasty (THA) undergo a subsequent contralateral THA. This study aims to determine if functional outcomes after primary THA predict outcomes in the subsequent primary THA of the contralateral side.MethodsA retrospective cohort of patients undergoing staged bilateral primary THA was reviewed. The Oxford Hip Score (OHS) was utilized as the functional outcome measurement tool and was assessed preoperatively and at one year postoperatively. The minimal clinically important difference (MCID) was assessed. Based on the first-side THA one-year outcomes, the odds of maintaining an MCID, or not, for the second-side THA were determined.ResultsThe study cohort consisted of 551 patients and 1102 primary THAs. The average postoperative OHSs were similar after the first and second THA. Patients achieving the MCID with the first-side surgery were 2.6 times (95% confidence interval 1.0 to 6.64, P = .04) more likely to achieve the MCID for the second-side surgery than patients failing to reach the MCID for their first-side surgery. After the first THA, 29 (5.3%) patients failed to reach the predefined MCID for the OHS compared with 54 (9.8%) patients undergoing their second THA (odds ratio: 1.96 [95% confidence interval: 1.23 to 3.1], χ² = 8.14, P = .005).ConclusionsFunctional outcomes after the first THA are predictive of functional outcomes of the second THA. Patients are more likely to achieve a clinically significant improvement after their first THA related to higher preoperative OHSs before the second THA.     

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis

BackgroundThere is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population.MethodsA systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4).ResultsA total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively).ConclusionLiver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.     

Contemporary Total Hip and Total Knee Arthroplasty Results in Patients with Hemochromatosis

BackgroundHemochromatosis can result in metabolic bone pathology (due to excessive iron absorption) and degenerative joint disease, leading to total joint arthroplasties. The aim of this study is to analyze the survivorship, complications, radiographic results, and clinical outcomes of patients with hemochromatosis who received either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA).MethodsWe identified 34 lower extremity arthroplasties in 29 patients with hemochromatosis performed between 2000 and 2016. There were 17 primary THAs in 15 patients and 17 primary TKAs in 14 patients. Mean age at arthroplasty was 63 years with 76% being male. The mean body mass index was 28 kg/m². Mean follow-up was 5 years.ResultsThe survivorship free from any revision for THAs was 94% at 10 years. One patient was revised for aseptic loosening of the femoral stem at 6 months. In THA patients, no infections, no other complications, and no radiographic evidence of aseptic loosening were identified. Harris Hip Scores improved from a mean of 55 preoperatively to 94 postoperatively (P < .001). The survivorship free from any revision for TKAs was 100% at 10 years. Two patients (12%) developed acquired idiopathic stiffness postoperatively; no infections were identified. There was no radiographic evidence of aseptic loosening in any TKA. Knee Society Scores improved from a mean of 61 preoperatively to 94 postoperatively (P < .001).ConclusionThis study found excellent survivorship, significant improvements in clinical outcomes, and a very low complication profile for both THA and TKA in patients with hemochromatosis.     

African American Patients Have Improved Functional Gains and Comparable Clinical Outcomes to Caucasian Patients After Total Hip and Knee Arthroplasty

BackgroundWith the increasing popularity of alternative payment models, minorities who use more postacute care resources may face difficulties with access to quality total hip arthroplasty (THA) and total knee arthroplasty (TKA) care. The purpose of this study is to compare differences in perioperative complications and functional outcomes between African American and Caucasian patients undergoing THA and TKA.MethodsWe reviewed a consecutive series of all primary THA and TKA patients at our institution from 2015 to 2018. Demographics, comorbidities, 90-day complications, readmissions, Veterans Rand 12-Item Health Survey (VR-12), Hip disability Osteoarthritis Outcome Score (HOOS), and Knee injury and Osteoarthritis Outcome Scores (KOOS) were compared between African American and Caucasian patients. A multivariate analysis was performed to control for confounding variables.ResultsOf the 5284 patients included in the study, 1041 were African American (24.5%). Although African American patients had lower preoperative HOOS/KOOS (33.5 vs 45.1, P < .001) and mental VR-12 scores (37.8 vs 51.5, P < .001) compared with Caucasian patients, there was no clinical difference at 1 year in HOOS/KOOS (50.2 vs 50.4), mental VR-12 (55.0 vs 52.6), or physical VR-12 scores (39.5 vs 39.8). When controlling for demographics and medical comorbidities, African American race was associated with increased rehabilitation facility discharge (odds ratio, 1.69; P < .001) but no difference in readmissions or complications.ConclusionAlthough African American patients had lower preoperative functional scores, they made improved postoperative gains when compared with Caucasian patients. Although there was no difference in postoperative complications, further studies should assess social causes for the increase in rehabilitation utilization rates in minority patients.     

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.     

Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients

BackgroundTranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA.MethodsWe retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery.ResultsThere was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA.ConclusionTXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.     

Relationships Between Preoperative Mental Health and Improvements in Patient-Reported Outcomes After Total Hip and Knee Arthroplasty

BackgroundPoor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups.MethodsElective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (≥75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoperative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately.ResultsMedian postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA, −4.0 high-THA, and −4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B = −0.94 - −0.68, P < .001-P = .01) but with improvements in joint health only in the low-THA group (B = −0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group.ConclusionPatients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and preoperative counseling.     

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BackgroundIt is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.MethodsPatient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).ResultsOne hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.ConclusionThese results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.