Effects of Depressive Disorders on Patients Undergoing Primary Total Knee Arthroplasty: A Matched-Control Analysis

BackgroundStudies evaluating the effects of depressive disorders in patients undergoing primary total knee arthroplasty (TKA) are sparse. Therefore, the purpose of this study is to investigate whether patients who have depressive disorders undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS), (2) readmission rates, (3) medical complications, (4) implant-related complications, and (5) costs of care.MethodsPatients with depressive disorders undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. The query yielded 138,076 patients who had (n = 23,061) or did not have (n = 115,015) depressive disorders. Primary outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, and costs of care. A P value less than .003 was considered statistically significant.ResultsPatients who have depressive disorders had significantly longer in-hospital LOS (6.2 days vs 3.1 days; P < .0001). Additionally, study group patients had a higher incidence and odds of readmissions (15.5% vs 12.1%; odds ratio [OR], 1.33; P < 001), medical complications (5.0% vs 1.6%; OR, 3.34; P < .0001), and implant-related complications (3.3% vs 1.7%; OR; 1.97; P < .0001) Study group patients also incurred significantly higher day of surgery ($12,356.59 vs $10,487.71; P < .0001) and 90-day costs ($23,386.17 vs $22,201.43; P < .0001).ConclusionAfter adjusting for age, sex, and comorbidities, this study demonstrated that patients who have depressive disorders have increased rates of in-hospital LOS, readmissions, complications, and cost. The study is useful in allowing orthopedists to adequately educate patients of potential complications which may occur.     

Is Iron Deficiency Anemia a Risk Factor for Poorer Outcomes in Primary Total Knee Arthroplasty?

BackgroundPatients undergoing total knee arthroplasty (TKA) commonly have concomitant iron deficiency anemia (IDA). The purpose of this study is to investigate the effect of IDA on (1) total in-hospital lengths of stay (LOS); (2) 90-day readmissions; (3) costs of care; (4) medical complications; and (5) and implant-related complications in patients who underwent primary TKA.MethodsPatients with and without IDA undergoing primary TKA were identified and matched through a nationwide administrative claims database that yielded 94,053 and 470,264 patients, respectively. Primary outcomes that were statistically analyzed included in-hospital LOS, readmission rates, costs of care, medical complications, and implant-related complications.ResultsPatients with IDA had longer in-hospital LOS (4 days vs 3 days; P < .0001), 90-day readmission rates (25.8% vs 16.3%; odds ratio [OR], 1.77; P < .0001), higher day of surgery ($13,079.42 vs $11,758.25; P < .0001), and total global 90-day episode of care costs ($17,635.13 vs $14,439.06; P < .0001) compared to patients who do not have IDA. Furthermore, IDA patients were found to have significantly higher incidence and odds of medical (3.53% vs 1.33%; OR, 2.71; P < .0001) and implant-related (3.80% vs 2.68%; OR, 1.43; P < .0001) complications following primary TKA.ConclusionThe effect of IDA on TKA outcomes may make a large impact on healthcare usage. We found that patients with IDA had poorer results in all the outcomes that were measured. Orthopedic surgeons can use this information to evaluate the need for IDA interventions before TKA which may contribute to lower rates of morbidity and mortality in TKA.     

Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis

BackgroundPigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs.MethodsPatients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch’s t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant.ResultsPVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001).ConclusionWithout controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.     

Chronic Obstructive Pulmonary Disease Is Associated With Higher Rates of Venous Thromboemboli Following Primary Total Knee Arthroplasty

BackgroundThere is discordance in the literature regarding the presence of chronic obstructive pulmonary disease (COPD) and the development of venous thromboemboli (VTEs). Therefore, the purpose of this study is to determine whether COPD patients undergoing primary total knee arthroplasty (TKA) have higher rates of (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) VTEs; and (4) costs of care.MethodsCOPD patients undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, gender, and medical comorbidities. Patients with a history of VTEs or hypercoagulable states were excluded. The query yielded 211,378 patients in the study (n = 35,230) and control (n = 176,148) cohorts. Outcomes analyzed included in-hospital LOS, readmission rates, VTEs, and costs of care. A P-value less than .01 was considered statistically significant.ResultsCOPD patients were found to have significantly longer in-hospital LOS (4 vs 3 days, P < .0001). Study group patients were also found to have significantly higher incidence and odds ratio (OR) of readmission rates (20.9% vs 16.3%; OR 1.36, P < .0001) and VTEs (1.75 vs .93; OR 1.18, P < .0001). Additionally, the study demonstrated that COPD patients incurred higher 90-day episode-of-care costs ($15,626.85 vs $14,471.29, P < .0001).ConclusionAfter adjusting for confounding variables, our study found an association between COPD and higher rates of developing VTEs following primary TKA. The study can be used by orthopedic surgeons to adequately counsel and educate these patients of the potential complications which may arise following their TKA.     

Implant-Related Complications Among Patients With Opioid Use Disorder Following Primary Total Hip Arthroplasty: A Matched-Control Analysis of 42,097 Medicare Patients

BackgroundOpioid use disorders (OUD) are a major cause of morbidity and mortality. The authors of this study hypothesize that patients who have an OUD will have greater relative risk of implant-related complications, periprosthetic joint infections (PJIs), readmission rates, and will incur greater costs compared to non-opioid use disorder (NUD) patients following primary total hip arthroplasty (THA).MethodsOUD patients who underwent a THA between 2005 and 2014 were identified and matched to controls in a 1:5 ratio according to age, sex, a comorbidity index, and various medical comorbidities yielding 42,097 patients equally distributed in both cohorts. Pearson’s chi-square analyses were used to compare patient demographics. Relative risk (RR) was used to analyze and compare risk of 2-year implant-related complications, 90-day PJIs, and 90-day readmission rates. Welch’s t-tests were used to compare day of surgery and 90-day episode-of-care costs between the cohorts. A P value less than .006 was considered statistically significant.ResultsOUD patients had higher incidences and risks of implant-related complications (11.99% vs 6.68%; RR, 1.74; P < .001), developing PJIs within 90 days (2.38% vs 1.81%; RR, 1.32; P = .001), and 90-day readmissions (21.49% vs 17.35%; RR, 1.23; P < .001). Additionally, the study demonstrated OUD patients incurred greater day of surgery ($14,384.30 vs $13,150.12, P < .0001) and 90-day costs ($21,183.82 vs $18,709.02, P < .0001) compared to controls.ConclusionAfter controlling for age, sex, a comorbidity index, and various medical complications, OUD patients are at greater risk to experience implant-related complications, PJIs, readmissions, and have greater costs following primary THA compared to non-OUD patients. This study should help orthopedic surgeons counsel their patients of potential complications which may arise following their primary THA.     

How does gout impact outcomes following primary shoulder arthroplasty?: Gout and shoulder arthroplasty

IntroductionStudies have shown that the overall prevalence of gout has increased. Data shows that patients with gout have worse outcomes following total joint arthroplasty, however studies investigating the effects of gout following primary total shoulder (TSA) and reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare outcomes of patients with and without gout undergoing primary shoulder arthroplasty, evaluating (1) in-hospital length of stay (LOS); (2) medical complications; (3) cost of care.MethodsA retrospective query using a nationwide administrative claims database was performed from January 2005 to March 2014 for all patients who underwent primary TSA and RSA for the treatment of glenohumeral osteoarthritis, yielding a total of 11,414 patients to be included. For the TSA cohort, 7702 patients were identified within the study (n = 1,185) and control (n = 6417) cohorts. Similarly, 3712 patients were identified within the RSA cohorts (gout n = 621 and control n = 3,091). Primary endpoints were in-hospital LOS, 90-day medical complications, and total global 90-day episode of care (EOC) costs. Multivariate logistic regression analyses were used to calculate the odds (OR) of medical complications, whereas Welch's t-tests were used to compare LOS and costs of care. A P value less than .05 was considered statistically significant.ResultsPatients with gout undergoing primary TSA (3- vs. 2-days, P < .0001) and RSA (3- vs. 2-days, P < .0001) had significantly longer in-hospital LOS. Gout patients undergoing either TSA (41.2 vs. 11.3%; OR: 3.30, P < .0001) or RSA had significantly higher incidence and odds (50.6 vs. 17.9%; OR: 2.10, P < .0001) of developing 90-day medical complications compared to their counterparts. Study group patients incurred significantly higher total global 90-day episode of care costs following both TSA ($15,007.84 vs. $13,447.06, P < .0001) and RSA ($19,659.27 vs. $16,783.70, P< .0001).ConclusionThis study demonstrates that patients with gout undergoing primary shoulder arthroplasty have longer in-hospital LOS, in addition to higher rates of complications, and increased costs of care. The study can be used by orthopedic surgeons to educate patients who have gout on complications which may occur following their surgical procedure.Level of EvidenceLevel III, retrospective comparative study.     

The association of alcohol use disorder with perioperative outcomes after primary total shoulder arthroplasty for glenohumeral osteoarthritis: a retrospective matched cohort study

BackgroundAccording to the World Health Organization, alcohol use disorder (AUD) is one of the leading mental health disorders in the United States. As the utilization of primary total shoulder arthroplasties (TSAs) continues to increase nationwide for the treatment of glenohumeral osteoarthritis (OA), studies evaluating the association of AUD with outcomes after primary TSA are warranted. Therefore, the aim of this study was to determine whether patients who undergo TSA and who have AUD have higher in-hospital lengths of stay (LOS), medical complications, and health care expenditures.MethodsThe Parts A and B 100% Medicare Claims Database were queried to identify patients who underwent primary TSA for glenohumeral OA and have AUD from January 1, 2005 to March 31, 2014. Patients were 1:5 ratio matched to a comparison cohort by age, sex, and various comorbid conditions. The query yielded 32,846 patients in the study (n = 5479) and comparison (n = 27,367) cohorts. The variables of interest include comparison of in-hospital LOS, 90-day medical complications, and day of surgery and 90-day health care costs. Welch’s t-tests were used to compare LOS, whereas multivariate logistic regression analyses were used to calculate the odds ratio (OR) of AUD on complications. A P value less than 0.001 was considered to be statistically significant.ResultsPatients with AUD had significantly longer in-hospital LOS (4 vs. 2 days, P < .0001), in addition to higher rates and odds of 90-day complications (30.44% vs. 7.94%; OR: 1.85, P < .0001) such as surgical site infections (1.15 vs. 0.24%; OR: 2.33, P < .0001), cerebrovascular accidents (5.06 vs. 1.23%; OR: 2.16, P < .0001), respiratory failures (5.79 vs. 1.52%; OR: 2.02, P < .0001), myocardial infarctions (1.53 vs. 0.43%; OR: 2.01, P < .0001), acute kidney injuries (6.55 vs. 1.34%; OR: 1.89, P < .0001), and other complications. In addition, patients in the study group incurred significantly higher day of surgery ($12,160.60 vs. $11,308.48, P < .0001) and 90-day episode of care costs ($14,493.13 vs. $13,087.55, P < .0001).ConclusionAs the prevalence of AUD continues to increase nationwide, understanding the association of AUD with outcomes after primary TSA for the treatment of glenohumeral OA is necessary. The current investigation is important as health care professionals and orthopedists can use this information to adequately educate patients on potential complications which may occur after their procedure.     

Increased Medical Complications,Revisions, In-Hospital Lengths of Stay,and Cost in Patients With Hypogonadism Undergoing Primary Total Knee Arthroplasty

BackgroundResearch regarding the impact of hypogonadism following primary total knee arthroplasty (TKA) is limited. Therefore, the purpose of this study is to investigate whether patients with hypogonadism undergoing primary TKA are at increased odds of (1) medical complications, (2) revisions, (3) in-hospital lengths of stay (LOSs), and (4) cost of care.MethodsA Humana patient population consisting of 8 million lives was retrospectively analyzed from 2007 to 2017 using International Classification of Disease, 9th Revision codes. Patients were filtered by male gender and patients with hypogonadism were matched to controls in a 1:4 ratio according to age and medical comorbidities. The query yielded 8393 patients with (n = 1681) and without (6712) hypogonadism undergoing primary TKA. Primary outcomes analyzed included medical complications, revision rates, in-hospital LOS, and cost of care. Logistic regression analysis was used to calculate odds ratios (OR) of 90-day medical complications and 2-year revisions. Welch’s t-test was used to test for significance in LOS and cost of care between cohorts. A P-value less than .05 was considered statistically significant.ResultsHypogonadal patients undergoing primary TKA were found to have increased incidence and odds (9.45% vs 4.67%; OR 2.12, P < .0001) of developing 90-day medical complications. Hypogonadal patients undergoing primary TKA were found to have a greater incidence and odds (3.99% vs 2.80%; OR 1.89, P < .0001) of 2-year revisions. Hypogonadal patients had a 6.11% longer LOS (3.47 vs 3.27 days, P = .02) compared to controls, and incurred greater 90-day costs ($15,564.31 vs $14,856.69, P = .018) compared to controls.ConclusionThis analysis of over 1600 patients demonstrates that patients with hypogonadism undergoing primary TKA have greater odds of postoperative medical complications, revisions, increased LOS, and cost of care.     

Crohn’s Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty

BackgroundAs the incidence and prevalence of Crohn’s disease continues to change worldwide, rates within North America have been increasing. The objective of this study was to evaluate whether patients who have Crohn’s disease undergoing primary total hip arthroplasties have worse outcomes compared with matched cohorts. Specifically, we evaluated 1) medical complications, 2) in-hospital lengths of stay (LOS), and 3) costs of care.MethodsTwo cohorts of patients who underwent primary total hip arthroplasties from January 1, 2005 to March 31, 2014 were identified from the Medicare claims of the PearlDiver platform. Cohorts were matched by age, sex, and following comorbidities—anemia, diabetes, hyperlipidemia, hypertension, malnutrition, pulmonary disease, and renal failure, yielding 55,361 patients within the study (n = 9229) and matching cohorts (n = 46,132). Outcomes assessed included 90-day medical complications, in-hospital LOS, and costs of care. A P-value less than .005 was considered statistically significant.ResultsPatients with Crohn’s disease were found to have significantly higher incidences and odds ratios of 90-day medical complications (30.2 vs 13.8; odds ratios: 2.2, P < .0001). They were also found to have significantly longer LOS (3.8- vs 3.6-days, P < .0001) and higher day of surgery ($12,662.00 vs 12,271.15, P < .0001) and 90-day episode costs ($16,933.18 vs $15,670.32, P < .0001).ConclusionCrohn’s disease is associated with higher rates of medical complications, longer in-hospital LOS, and increased costs of care. This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications in these patients.     

Paget’s Disease in Primary Total Hip Arthroplasty Is Associated With Greater In-Hospital Lengths of Stay,Costs, and Complications

BackgroundThere are few well-powered studies investigating the association of Paget’s disease of bone on patients undergoing primary total hip arthroplasty (THA). This study utilized a nationwide database to determine whether Paget’s patients undergoing primary THA are associated with higher rates of (1) lengths of stay (LOS); (2) costs; and (3) complications (medical/surgical and implant-related).MethodsUsing International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, Paget’s patients undergoing primary THA were identified and matched to non-Paget’s patients in a 1:5 ratio by age, sex, and comorbidities utilizing the PearlDiver database. This resulted in 21,714 patients in Paget’s (n = 3619) and non-Paget’s (n = 18,095) cohorts. Outcomes assessed included LOS, episode-of-care costs, medical/surgical complications, and implant-related complications. A P value less than .003 was considered statistically significant.ResultsCompared to the matched cohort, Paget’s patients undergoing primary THA had significantly longer LOS (P < .0001), higher 90-day total global episode-of-care costs (P < .0001), higher 90-day medical and surgical complications (P < .0001), and higher implant-related complications (P < .0001).ConclusionWe found that Paget’s was associated with higher rates of LOS, costs, and complications. Although there was an association found, the risk appears reasonably low compared to the matched cohort. The study can be utilized by orthopedic professionals to counsel and educate these patients of potential complications which may occur following their procedure.     

Patients Who Have Cannabis Use Disorder Have Higher Rates of Venous Thromboemboli,Readmission Rates,and Costs Following Primary Total Knee Arthroplasty

BackgroundStudies have shown that cannabis can interfere with hematological parameters and platelet morphology. The purpose of this study is to investigate whether patients with cannabis use disorder undergoing primary total knee arthroplasty (TKA) have higher rates of (1) venous thromboemboli (VTEs); (2) readmissions; and (3) costs.MethodsStudy group patients undergoing primary TKA were identified from a large, nationwide database. Patients who had a history of VTEs, deep vein thromboses (DVTs), pulmonary emboli (PEs), and coagulopathies before their TKA were excluded. Study group patients were matched to controls in a 1:4 ratio by age, sex, a comorbidity index, and medical comorbidities. The query yielded 18,388 patients (cannabis = 3680; controls = 14,708). Outcomes analyzed included rates of 90-day VTEs, DVTs, and PEs, in addition to 90-day readmissions and costs. A P value less than .01 was considered statistically significant.ResultsPatients who have cannabis use disorder were found to have significantly higher incidence and odds (2.79% vs 1.78%; odds ratio [OR], 1.58; P < .0001) of VTEs, DVTs (2.41% vs 1.44%; OR, 1.68; P < .0001), and PEs (0.97% vs 0.62%; P = .01). Readmissions were significantly higher (27.03% vs 23.18%; OR, 1.22; P < .0001) in patients who have cannabis use disorder. Patients with cannabis use disorder have significantly higher day of surgery ($14,024.88 vs $12,127.49; P < .0001) and 90-day costs ($19,155.45 vs $16,315.00; P < .0001).ConclusionThis study found that patients who have a cannabis use disorder have higher rates of thromboembolic complications, readmission rates, and costs following primary TKA compared to a matched cohort.     

Rheumatoid Arthritis Is Associated With Thromboembolic Complications Following Primary Total Knee Arthroplasty

BackgroundRecent studies have demonstrated patients with rheumatoid arthritis (RA) have deranged coagulation parameters predisposing them to venous thromboembolisms (VTEs). Therefore, the purpose of this study was to investigate whether patients who have RA undergoing primary TKA have higher rates of (1) VTEs; (2) readmission rates; and (3) costs of care.MethodsPatients who have RA undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. Exclusions included patients with a history of VTEs and hypercoagulable states. Primary outcomes analyzed included rates of 90-day VTEs, along with lower extremity deep vein thromboses and pulmonary embolisms, 90-day readmission rates, in addition to day of surgery, and 90-day costs of care. A P-value less than .05 was considered statistically significant.ResultsPatients who have RA were found to have significantly higher incidence and odds (OR) of VTEs (1.9 vs 1.3%; OR: 1.51, P < .0001), deep vein thromboses (1.6 vs 1.1%; OR: 1.55, P < .0001), and pulmonary embolisms (0.4 vs 0.3%; OR: 1.26, P = .0001). Study group patients also had significantly higher incidence and odds of readmissions (21.6 vs 14.1%; OR: 1.67, P < .0001) compared to controls. In addition, RA patients incurred significantly higher day of surgery ($12,475.17 vs $11,428.96; P < .0001) and 90-day costs of care ($15,937.34 vs $13,678.85; P < .0001).ConclusionAfter adjusting for age, sex, and comorbidities, the study found patients who have RA undergoing primary TKA had significantly higher rates of VTEs, readmissions, and costs.     

The Importance of Oral History: Does Dental Implant Placement or Caries One Year Before or After Primary Total Knee Arthroplasty Increase Medical Complications and Periprosthetic Joint Infections?

BackgroundConsensus regarding prior dental problems on the outcomes of total knee arthroplasty (TKA) patients is lacking. Therefore, our objectives were to determine the association of dental caries or dental implant placement in TKA patients on the following: (1) medical complications; (2) health care utilization (lengths of stay and readmissions); (3) implant-related complications; and (4) expenditures.MethodsA retrospective query was performed using an administrative claims database for 3 patient cohorts undergoing primary TKA from 2010 to 2020. Patients who had a history of dental caries or implant placement 1 year prior to TKA (n = 1,466) and 1 year after TKA (n = 1,127) were case-matched to patients who did not have a dental history by age and comorbidities. Outcomes included 90-day complications, health care utilization parameters, 2-year implant complications, and expenditures. Logistic regression models computed odds ratios (OR) of complications and readmissions. P values less than 0.005 were significant.ResultsPatients who had a dental implant placement prior to TKA had higher frequency of complications (20.05 versus 14.01%; OR: 1.53, P < .0001), including myocardial infarctions (2.52 versus 1.23%; OR: 2.08, P = .0002) and pneumonia (2.52 versus 1.24%; OR: 2.06, P = .0002). Lengths of stay (3.28 versus 2.98 days; P = .255), readmission rates (4.71 versus 4.28%; P = .470), and implant-related complications including periprosthetic joint infections (3.14 versus 2.63%; OR: 1.20, P = .279) were similar between patients lacking dental history. Expenditures were higher in patients who had a postoperative and preoperative dental history ($19,252 versus $19,363 versus 17,980; P < .001).ConclusionDental caries or implant placement may reflect overall worse medical condition resulting in more complications and higher costs after TKA. Dental history screening preoperatively may assist arthroplasty surgeons in minimizing complications.     

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.     

The Use of Cementless Components Does Not Significantly Increase Procedural Costs in Total Knee Arthroplasty

BackgroundModern cementless total knee arthroplasty (TKA) designs have shown promising early clinical success; however, concerns exist regarding the higher cost of the cementless implants. The purpose of this study is to evaluate the total facility cost of cementless vs traditional cemented TKA along with the effect of cementless fixation on short-term outcomes.MethodsWe reviewed a consecutive series of patients between 2015 and 2017 who underwent either cementless or cemented primary TKA. Itemized facility costs were calculated for every procedure using a time-driven activity-based costing algorithm. Controlling for demographic variables and medical comorbidities, we performed a multivariate analysis to identify independent risk factors for facility costs following TKA. Short-term outcome metrics including complications, readmissions, and patient-reported outcomes were compared between groups.ResultsAmong the 2426 primary TKA patients in this study, 119 (4.91%) were performed using cementless implants. When compared to cemented TKA, cementless TKA patients had higher implant costs ($3047.80 vs $2808.73, P < .0001), but lower supply costs ($639.49 vs $815.57, P < .0001) and lower operating room personnel costs ($982.01 vs $1238.26, P < .0001). When controlling for confounding variables, cementless fixation did not have a significant effect on total facility cost or outcomes.ConclusionIn conclusion, the use of cementless TKA implants did not significantly increase total procedural costs when compared to traditional cemented TKA components at our institution. Our data suggest that the increased cost of a cementless implant is recouped through savings in cost of cement and supplies, as well as shorter operative times. The authors encourage investigators at other institutions to use the authors' methodology to evaluate (preferably in a prospective manner) whether the findings from this study can be corroborated.     

The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates

BackgroundTo reduce the substantial clinical and financial burden of periprosthetic joint infection (PJI), some surgeons advocate for the use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA), although its effectiveness continues to be debated in the literature. The purpose of this study was to determine whether the routine use of ALBC is cost-effective in reducing PJI after primary TKA.MethodsWe retrospectively reviewed a consecutive series of patients undergoing cemented primary TKA at two hospitals within our institution from 2015 to 2017. We compared demographics, comorbidities, costs, and PJI rates between patients receiving ALBC and plain cement. We performed a multivariate regression analysis to determine the independent effect of ALBC on PJI rate. We calculated readmission costs for PJI and reduction in PJI needed to justify the added cost of ALBC.ResultsOf 2511 patients, 1077 underwent TKA with ALBC (43%), with no difference in PJI rates (0.56% vs 0.14%, P = .0662) or complications (1.2% vs 1.6%, P = .3968) but higher cement costs ($416 vs $117, P < .0001) and overall procedure costs ($6445 vs $5.968, P < .0001). ALBC had no effect on infection rate (P = .0894). Patients readmitted with PJI had higher overall 90-day episode-of-care claims costs ($49,341 vs $19,032, P < .001). To justify additional costs, ALBC would need to prevent infection in one of every 101 patients.ConclusionRoutine use of ALBC in primary TKA is not cost-effective, adding $299 to the cost of episode of care without a reduction in PJI rate. Further study is needed to determine whether select use of ALBC would be justified in high-risk patients.     

From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative improved quality and reduced costs following total hip (THA) and knee arthroplasty (TKA). In October 2018, the BPCI-Advanced program was implemented. The purpose of this study is to compare the quality metrics and performance between our institution’s participation in the BPCI program with the BPCI-Advanced initiative.MethodsWe reviewed a consecutive series of Medicare primary THA and TKA patients. Demographics, medical comorbidities, discharge disposition, readmission, and complication rates were compared between BPCI and BPCI-Advanced groups. Medicare claims data were used to compare episode-of-care costs, target price, and margin per patient between the cohorts.ResultsCompared to BPCI patients (n = 9222), BPCI-Advanced patients (n = 2430) had lower rates of readmission (5.8% vs 3.8%, P = .001) and higher rate of discharge to home (72% vs 78%, P < .001) with similar rates of complications (4% vs 4%, P = .216). Medical comorbidities were similar between groups. BPCI-Advanced patients had higher episode-of-care costs ($22,044 vs $18,440, P < .001) and a higher mean target price ($21,154 vs $20,277, P < .001). BPCI-Advanced patients had a reduced per-patient margin compared to BPCI ($890 loss vs $1459 gain, P < .001), resulting in a $2,138,670 loss in the first three-quarters of program participation.ConclusionDespite marked improvements in quality metrics, our institution suffered a substantial loss through BPCI-Advanced secondary to methodological changes within the program, such as the exclusion of outpatient TKAs, facility-specific target pricing, and the elimination of different risk tracks for institutions. Medicare should consider adjustments to this program to keep surgeons participating in alternative payment models.     

Impact of Postoperative Zolpidem Use on Primary Total Knee Arthroplasty: A Retrospective Matched-Controlled Analysis of a Private Insurance Database

IntroductionZolpidem has gained popularity as a pharmaceutical therapy for insomnia, being the most prescribed hypnotic in the United States today. However, it is associated with increased mortality and morbidity. Literature regarding zolpidem use in the total knee arthroplasty (TKA) population is limited. The aim of the study was to analyze postoperative zolpidem use in the TKA population regarding medical and implant complications, falls, and readmission.MethodsThe study group was queried according to zolpidem use. Controls consisted of patients who underwent primary TKA without a history of hypnotic drug use. Study group patients were matched to controls in a 1:5 ratio by demographics and comorbidities. Results yielded 99,178 study participants and 495,795 controls. Primary endpoints included 90-day medical and implant complications, fall risk, and readmission. Chi-squared test was used to compare categorical variables. Multivariate logistic regression was used to calculate odds (OR) for complications, fall risk, and readmission. A P value less than 0.05 was considered statistically significant.ResultsStudy group patients had increased odds of medical complications (OR: 1.76, 95% CI: 1.71-1.82, P < .0001) and implant complications (OR: 1.35, 95% CI: 1.23-1.47, P < .0001) compared to controls. Furthermore, patients in the study group were found to have an increased risk of 90- day falls (OR: 1.16, 95% CI: 1.11-1.21, P < .0001). Readmission was similar to controls (5.10% vs 4.84%, P = .12).ConclusionZolpidem use following primary TKA is associated with the risk of morbidity and falls. The findings are consistent with the literature regarding zolpidem. These findings may affect discussion between orthopedic surgeons and patients in the decision-making process prior to undergoing TKA.     

Trends in Length of Stay and 30-Day Complications After Total Knee Arthroplasty: An Analysis From 2006 to 2016

BackgroundHospital length of stay (LOS) is a quality metric and target of recent efforts in the last decade to decrease healthcare costs and postoperative nosocomial complications after total knee arthroplasty (TKA). However, decreasing LOS has raised concerns of possible increased complication and readmission rates. We present a decade-long analysis in trends of LOS and 30-day complication and unplanned readmissions following TKA.MethodsThe National Surgical Quality Improvement Program registry was utilized to identify patients undergoing elective primary TKA between 2006 and 2016. Three cohorts of patients were created based on year of surgery (2006-2009 [N = 7111], 2010-2013 [N = 71,943], and 2014-2016 [N = 142,710]). Patient demographics, perioperative variables, LOS, 30-day postoperative complications, and readmission rates were analyzed between the 3 cohorts using bivariate and multivariate analyses.ResultsLOS decreased significantly over time when the 2006-2009 cohort (3.7 days) was compared to the 2010-2013 cohort (3.3 days, P < .001) and 2014-2016 cohort (3.0 days, P < .001). Similarly, there was a decrease in the rate of total 30-day complications in the 2006-2009 cohort (5.37%) compared to 2010-2013 (3.86%) and 2014-2016 (3.13%, P < .001), with significantly lower rates of deep vein thrombosis, sepsis, and urinary tract infection in the latter cohorts. Decreasing rates of 30-day readmission were also observed in the 2010-2013 cohort (3.63%) compared to 2013-2016 cohort (3.23%, P < .001).ConclusionIn the last decade, there has been a trend toward decreasing LOS after TKA. Despite concerns about early discharge, data from a national registry demonstrated a simultaneous decrease in total 30-day complication and readmission rates.Level of EvidenceIII, Retrospective cohort study.     

Comparison Study of Patient Demographics,Risk Factors,and Lengths of Stay for Postoperative Ileus After Primary Total Knee Arthroplasty

BackgroundPostoperative ileus is a potential complication after orthopedic surgery, which has not been well studied after total knee arthroplasty (TKA). The aims of this study were to analyze rates of postoperative ileus; patient demographic profiles; in-hospital lengths of stay (LOS); and patient-related risk factors for postoperative ileus after primary TKA.MethodsA query was performed from January 1, 2005 to March 31, 2014 using the Medicare Standard Analytical Files. Patients who underwent primary TKA and developed postoperative ileus within 3 days after their index procedure were identified. Patients who did not develop ileus represented controls. Primary outcomes analyzed and compared included patient demographics, risk factors, and in-hospital LOS. A P value less than .05 was considered statistically significant.ResultsIleus patients were older, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (8 vs 6; P < .0001) compared with controls. Male patients (odds ratio [OR], 2.12; P < .0001), patients with preoperative electrolyte/fluid imbalance (OR, 3.40; P < .001), patients older than 70 years (OR, 1.62-2.33; P < .015), and body mass indices greater than 30 kg/m² (OR, 1.79-2.00; P < .001) were at the greatest risk of developing ileus. In addition, ileus patients had significantly longer in-hospital LOS (5.42 vs 3.22 days; P < .001).ConclusionThe study demonstrated differences in patient demographics, patient-related risk factors, and an increased in-hospital LOS for ileus patients after primary TKA. The study is important as it can allow orthopedists to properly identify and optimize patients with certain risk factors to potentially mitigate this adverse event from occurring.