A Comparison of Risk of Dislocation and Cause-Specific Revision Between Direct Anterior and Posterior Approach Following Elective Cementless Total Hip Arthroplasty

BackgroundUse of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased over the last decade. We sought to investigate whether (1) a difference exists in dislocation risk for DAA compared with posterior THA, (2) a difference exists in risk for specific revision reasons, and (3) the likelihood of adverse 90-day postoperative events differs.MethodsWe conducted a cohort study using data from Kaiser Permanente’s Total Joint Replacement Registry. Patients aged ≥18 years who underwent primary cementless THA for osteoarthritis with a highly cross-linked polyethylene liner were included (2009-2017). Multivariable Cox proportional hazards regression was used to evaluate dislocation and cause-specific revision risks, and multivariable logistic regression was used to evaluate 90-day emergency department visits, 90-day unplanned readmissions, and 90-day complications (including deep infection, deep vein thrombosis, and pulmonary embolism).ResultsOf 38,399 primary THA, 6428 (16.7%) were DAA. All-cause revision at 2-years follow-up was 1.78% (95% confidence interval [CI] = 1.46-2.17) for DAA and 2.28% (95% CI = 2.11-2.45) for posterior. After adjusting for covariates, DAA had a lower risk of dislocation (hazard ratio [HR] = 0.39, 95% CI = 0.29-0.53), revision for instability (HR = 0.33, 95% CI = 0.18-0.58), revision for periprosthetic fracture (HR = 0.57, 95% CI = 0.34-0.96), and readmission (odds ratio = 0.82, 95% CI = 0.67-0.99) compared with posterior approach but a higher risk of revision for aseptic loosening (HR = 2.26, 95% CI = 1.35-3.79).ConclusionWhile the DAA associated with lower risks of dislocation and revision for instability and periprosthetic fracture, it is associated with a higher revision risk for aseptic loosening. Surgeons should discuss these risks with their patients.     

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty,a National Registry Study

BackgroundThe purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry.MethodsAdult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA.ResultsOn multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions.ConclusionBlack, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.     

Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty

BackgroundAs indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years.MethodsA Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years.ResultsPatients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability.ConclusionIdentified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability.Level of EvidenceIII.     

Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England,Wales, Northern Ireland and the Isle of Man

BackgroundRegional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world’s largest joint replacement registry.MethodsWe studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes.ResultsLength of stay was reduced with regional anesthesia compared with general anesthesia (THR = −0.49 days, 95% confidence interval [CI] = −0.51 to −0.47 days, P < .001; TKR = −0.47 days, CI = −0.49 to −0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality.ConclusionRegional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.     

Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty?

BackgroundWe sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint.MethodsWe conducted a matched cohort study using data from Kaiser Permanente’s arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models.ResultsNo difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63).ConclusionPatients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients.Level of EvidenceLevel III.     

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BackgroundDecreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.ResultsWhen comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.ConclusionThe unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.Level of EvidenceIII.     

Predicting Inpatient Status After Primary Total Knee Arthroplasty in Medicare-Aged Patients

BackgroundThe Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from its inpatient only (IPO) list as of January 1, 2018. The purpose of this study was to establish a risk-stratifying nomogram to aid in determining the need for inpatient admission among Medicare-aged patients undergoing primary TKA.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients aged ≥65 years who underwent primary TKA between 2006 and 2015. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and perioperative variables were incorporated in a multivariate logistic regression model to yield a risk stratification nomogram.ResultsSixty-one thousand two hundred eighty-four inpatient and 26,066 outpatient admissions were analyzed. Age >80 years (odds ratio [OR] = 2.27, P < .0001, 95% confidence interval [CI] = 2.13-2.42), simultaneous bilateral TKA (OR = 2.02, P < .0001, 95% CI = 1.77-2.30), dependent functional status (OR = 1.95, P < .0001, 95% CI = 1.62-2.35), metastatic cancer (OR = 1.91, P = .055, 95% CI = 0.99-3.73), and female gender (OR = 1.76, P < .0001, 95% CI = 1.70-1.82) were the greatest determinants of inpatient stay. The resulting predictive model demonstrated acceptable discrimination and excellent calibration.ConclusionOur model enabled a reliable and straightforward identification of the most suitable candidates for inpatient admission in Medicare aged–patients undergoing primary TKA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram.     

Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundThere is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA.MethodsWe searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders.ResultsThe risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I² = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I² = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001).ConclusionMental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.     

High Rate of Re-Revision in Patients Less Than 55 Years of Age Undergoing Aseptic Revision Total Knee Arthroplasty

BackgroundThere are limited data on the outcomes of revision total knee arthroplasty in young patients. We sought to characterize the re-revision-free survival and risk factors for re-revision in patients less than 55 years who underwent aseptic revision TKA.MethodsWe retrospectively reviewed 197 revision TKAs at a mean follow-up of 5 years. Mean age was 49 years; mean body mass index was 31 kg/m². Twenty-seven (14%) patients had at least 1 prior revision TKA. The most common indications for revision included instability (29%), arthrofibrosis (26%), and aseptic loosening (24%). Constraint included the following: 59 posterior-stabilized (30%), 123 varus-valgus constrained (62%), and 15 hinged (8%). Components revised included the following: 93 femur/tibia (47%), 68 polyethylene-only (35%), 19 femur-only (10%), and 17 other (9%). Survivorship free from re-revision was calculated via the Kaplan-Meier method and a multivariate Cox proportional regression was utilized to identify risk factors for re-revision.ResultsSurvivorship free from any re-revision at 5 years was 80%. In the multivariate analysis, patients with a prior revision (hazard ratio [HR] = 2.78, P = .02), an isolated polyethylene exchange (HR = 3.0, P = .004), and a hinged prosthesis (HR = 3.47, P = .05) were significant risk factors for lower revision-free survival. Forty-two patients (21%) underwent re-revision, most commonly for periprosthetic joint infection (7%), instability (6%), and aseptic loosening (5%). Re-revision occurred in 18/68 (26%) patients undergoing an isolated polyethylene exchange.ConclusionPatients less than 55 years undergoing revision TKA have a modest 5-year revision-free survival of 80%. Patients with prior revision TKAs (HR = 2.78), hinge type prostheses (HR = 3.47), and polyethylene-only revisions (HR = 3.0) had higher revision rates.     

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty

BackgroundDespite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen.MethodsA retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs).ResultsSSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), “other” antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and “other” antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses.ConclusionAntibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.     

Disparities in Elective and Nonelective Total Hip Arthroplasty

BackgroundPrior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.MethodsData were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as “elective” or “nonelective” if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.ResultsAfter multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.ConclusionDemographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.     

Comparison of Modular Conventional and High-Flexion Posterior-Stabilized Total Knee Arthroplasties in the Same Patients at a Mean Follow-Up of 15 Years

BackgroundAs previous studies are limited to short-term clinical data on conventional and high-flexion total knee arthroplasties (TKAs), long-term clinical data on these TKAs remain unclear. Therefore, we evaluated long-term functional outcome, range of knee motion, revision rate, implant survival, and the prevalence of osteolysis after conventional and high-flexion TKAs in the same patients.MethodsThe authors evaluated a cohort of 1206 patients with a mean age of 65.3 ± 7 years (range: 22-70) who underwent bilateral simultaneous sequential TKAs. One knee received a conventional TKA and the other received a high-flexion TKA. The mean duration of follow-up was 15.6 years (range: 14-17).ResultsNo significant differences were found between the 2 groups at the latest follow-up with respect to Knee Society score (93 vs 92 points, P = .765), pain score (45 vs 44 points, P = .641), range of knee motion (125° vs 126°, P = .712), and radiographic and computed tomography scan results. Furthermore, no significant revision rate differences were found between the 2 groups (1.3% for conventional TKA vs 1.6% for high-flexion TKA; P = .137). There was no osteolysis recorded in either group. The rate of survivorship free of implant revision or aseptic loosening was 98.7% (95% CI = 91-100) for conventional TKA and 98.4% (95% CI = 91-100) for high-flexion TKA at 17 years.ConclusionAt the latest follow-up, we were not able to demonstrate any significant difference between conventional and high-flexion TKAs with respect to functional outcome scores, range of knee motion, revision rate, implant survival, and prevalence of osteolysis.     

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BackgroundRacial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.MethodsThis is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005–2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.ResultsOf 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1–1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1–2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4–1.9), and sepsis (OR: 1.7; 95% CI 1.4–2.02) compared to White patients.ConclusionsRacial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.     

Predictive Factors for Revision and Survivorship Analysis of a Prevalent 36-mm Metal-on-Metal Total Hip Replacement System: A Large Single-Center Retrospective Cohort Study

BackgroundTo our knowledge, this is the largest single-center cohort of the 36-mm Corail-Pinnacle metal-on-metal total hip replacements system, aiming to determine 10-year survivorship and identify predictors of revision. We further assessed year of implantation given reports of manufacturing variations affecting shells made after 2006 predisposing these components to increasing wear.MethodsAll Corail-Pinnacle 36-mm metal-on-metal hips implanted in a single center (2005-2012). The effect of patient and implant-related variables, and year of implantation on revision risk was assessed using Kaplan-Meier, Cox regression, and interrupted time series analysis.ResultsIn total, 1212 metal-on-metal total hip replacements were implanted with a 10-year survival rate of 83.4% (95% confidence interval [CI] = 81.3-85.5). Mean follow-up duration was 7.3 years with 61% of patients reaching a minimum of 7 years of follow-up. One hundred nineteen patients required revision surgery (9.8%). Univariate analysis identified female gender (hazard ratio [HR] = 1.608, CI = 1.093-2.364, P = .016), age at implantation (HR = 0.982, CI = 0.968-0.997, P = .019), smaller 50-mm to 54-mm cup diameter (HR = 1.527, CI = 1.026-2.274, P = .037), and high-offset stems (HR = 2.573, CI = 1.619-4.089, P < .001) as predictors of revision. Multivariate modeling confirmed female gender and high-offset stems as significant predictors of revision. For components implanted after 2007, the number of revisions showed no statistically significant step increase compared to pre-2007 implantation.ConclusionWe observed a high 10-year failure rate (16.6%) with this implant, mostly due to adverse reaction to metal debris. Female gender and high femoral offset stems were significant predictors for all-cause revision. Year of implantation was not significantly associated with an increasing number of revisions from 2007 onwards, although further studies to validate the impact of manufacturing discrepancies are recommended.     

Racial disparities in outcomes for extracorporeal membrane oxygenation in the United States

BackgroundRacial disparities in extracorporeal membrane oxygenation (ECMO) outcomes in patients with a broad set of indications are not well documented.MethodsAdults requiring ECMO were identified in the 2016–2019 National Inpatient Sample. Patient and hospital characteristics, including mortality, clinical outcomes, and resource utilization were analyzed using multivariable regressions.ResultsOf 43,190 adult ECMO patients, 67.8% were classified as White, 18.1% Black, and 10.4% Hispanic. Although mortality for Whites declined from 47.5 to 41.0% (P = 0.002), it remained steady for others. Compared to White, Asian/Pacific Islander (PI) race was linked to increased odds of mortalty (AOR = 1.4, 95% CI = 1.1–2.0). Black race was associated with increased odds of acute kidney injury (AOR = 1.4, 95%-CI: 1.2–1.7), while Hispanic race was linked to neurologic complications (AOR 21.6; 95% CI 1.2–2.3). Black and Hispanic race were also associated with increased incremental costs.ConclusionsRace-based disparities in ECMO outcomes persist in the United States. Further work should aim to understand and mitigate the underlying reasons for such findings.     

No Threshold Exists for Recommending Revision Surgery in Metal-on-Metal Hip Arthroplasty Patients With Adverse Reactions to Metal Debris: A Retrospective Cohort Study of 346 Revisions

BackgroundSurgeons currently have difficulty when managing metal-on-metal hip arthroplasty (MoMHA) patients with adverse reactions to metal debris (ARMD). This stems from a lack of evidence, which is emphasized by the variability in the recommendations proposed by different worldwide regulatory authorities for considering MoMHA revision surgery. We investigated predictors of poor outcomes following MoMHA revision surgery performed for ARMD to help inform the revision threshold and type of reconstruction.MethodsWe retrospectively studied 346 MoMHA revisions for ARMD performed at 2 European centers. Preoperative (metal ions/imaging) and intraoperative (findings, components removed/implanted) factors were used to predict poor outcomes. Poor outcomes were postoperative complications (including re-revision), 90-day mortality, and poor Oxford Hip Score.ResultsPoor outcomes occurred in 38.5%. Shorter time (under 4 years) to revision surgery was the only preoperative predictor of poor outcomes (odds ratio [OR] = 2.12, confidence interval [CI] = 1.00-4.46). Prerevision metal ions and imaging did not influence outcomes. Single-component revisions (vs all-component revisions) increased the risk of poor outcomes (OR = 2.99, CI = 1.50-5.97). Intraoperative modifiable factors reducing the risk of poor outcomes included the posterior approach (OR = 0.22, CI = 0.10-0.49), revision head sizes ≥36 mm (vs <36 mm: OR = 0.37, CI = 0.18-0.77), ceramic-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.30, CI = 0.14-0.66), and metal-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.37, CI = 0.17-0.83).ConclusionNo threshold exists for recommending revision in MoMHA patients with ARMD. However postrevision outcomes were surgeon modifiable. Optimal outcomes may be achieved if surgeons use the posterior approach, revise all MoMHA components, and use ≥36 mm ceramic-on-polyethylene or metal-on-polyethylene articulations.     

Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty

BackgroundRevision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis.MethodsA retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission.ResultsThe reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission.ConclusionBased on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.     

Prior Nonarthroplasty Surgery Increases Risk of Complication in Primary Total Knee Arthroplasty

BackgroundPrior ipsilateral knee surgery may increase the risk for complications after total knee arthroplasty (TKA). It remains unclear if the extent of previous surgery affects those risks disparately. The purpose of this study is to evaluate prior nonarthroplasty bony procedure (BP) and soft tissue only procedure (STP) as a potential risk factor for complications after TKA and determine the association with charges or reimbursement of the primary TKA.MethodsPatients who underwent primary TKA with previous knee surgery were identified using a national Medicare database and matched 1:5 to controls without prior knee surgery. Rates of postoperative medical and surgical complications were calculated in addition to hospital-associated charges and reimbursements. Logistic regression analysis was used to control for confounding factors.ResultsPatients who underwent BP (n = 835) had increased risk of readmission (58.6% vs 45.3%, odds ratio (OR) 1.72, 95% confidence interval (CI) 1.59-1.85, P < .001) and emergency room visits (14.5% vs 10.4%, OR 1.44, 95% CI 1.29-1.61, P = .001). Patients who underwent STP (n = 6766) had increased risk of readmission (58.1% vs 45.2%, OR 1.69, 95% CI 1.64-1.73, P < .001), emergency room visits (12.6% vs 0.7%, OR 1.33, 1.28-1.39, P < .001), revision (1.8% vs 1.4%, OR 1.33, 95% CI 1.21-1.47, P = .006), cerebrovascular accident (2.3% vs 1.7%, OR 1.33, 95% CI 1.22-1.46, P = .002), and venous thromboembolism (3.8% vs 3.2%, OR 1.21, 95% CI 1.13-1.29, P = .009). Prior surgery was associated with increased charges and reimbursements.ConclusionPrior ipsilateral knee surgery is associated with significantly increased risks of postoperative complications after primary TKA. Interestingly, previous STP but not BP increased the risk of short-term revision and venous thromboembolism.