Total Joint Arthroplasty and Osteoporosis: Looking Beyond the Joint to Bone Health

BackgroundMetabolic bone diseases in the total joint arthroplasty (TJA) population are undertested and undertreated, leading to increased risk of adverse outcomes such as periprosthetic fractures. This study aims to better characterize the current state of bone care in TJA patients using Fracture Risk Assessment Tool (FRAX) score risk stratifications.MethodsIn total, 505 consecutive TJA patients who meet the Endocrine Society guidelines for osteoporosis screening were included for review. They were divided into a high risk or low risk group depending on FRAX scores and were compared based on screening, diagnosis, and treatment of metabolic bone disease. Logistic regression models were used to analyze factors influencing screening and treatment. A population analysis involving 2,000 TJA patients, and a complication analysis involving 40 periprosthetic fracture patients were conducted.ResultsAmong high risk patients undergoing TJA, 90% did not receive any pharmacological treatment for osteoporosis, 45% were not treated with vitamin D or calcium, and 88% did not receive bone density testing in the routine care period. Among patients with pre-existing osteoporosis undergoing TJA, 80% were not treated with any osteoporosis medications and 33% of these patients were not taking vitamin D or calcium. Female gender and past fracture history contributed to whether patients received screening and treatment. Patients with periprosthetic hip fractures have significantly higher FRAX scores compared to control THA patients.ConclusionThere are significant gaps in metabolic bone care of the geriatric TJA population regarding both screening and treatment. Metabolic bone care and risk identification with FRAX should be highly considered for TJA patients.     

Alpha-Defensin Offers Limited Utility in Work-Up Prior to Reimplantation in Chronic Periprosthetic Joint Infection in Total Joint Arthroplasty Patients

BackgroundAlpha-defensin (AD) is a synovial biomarker included in the 2018 consensus criteria for diagnosing periprosthetic joint infection (PJI). Its value in assessing eradication of infection prior to second stage reimplantation is unclear. The purpose of this study was to evaluate the impact of AD on eligibility for reimplantation following resection for chronic PJI.MethodsThis study included patients who previously underwent resection arthroplasty for PJI. Synovial fluid aspirated from 87 patients was retrospectively reviewed. All patients completed a 6-week course of intravenous antibiotics and an appropriate drug holiday. Synovial white blood cell count, percentage neutrophils, and culture from the AD immunoassay laboratory were reviewed with serum erythrocyte sedimentation rate and C-reactive protein values from our institution. A modified version of the 2018 consensus criteria was used, including white blood cell count, percentage neutrophils, erythrocyte sedimentation rate, and C-reactive protein. AD was then added to determine if it changed diagnosis or clinical management.ResultsFour patients were categorized as “infected” (score >6), none exhibited a positive AD or positive culture. Sixty eight patients were diagnosed as “possibly infected” (score 2 to 5), none had a positive AD, and one had a positive culture (Cutibacterium acnes). AD did not change the diagnosis from “possibly infected” to “infected” in any case or alter treatment plans. Fifteen patients had a score of <2 (not infected) and none had a positive AD.ConclusionThe routine use of AD in the work-up prior to a second-stage arthroplasty procedure for PJI may not be warranted.     

Does Prior Bariatric Surgery Improve Outcomes Following Total Joint Arthroplasty in the Morbidly Obese? A Meta-Analysis

Background

There remains a controversy regarding the risks in subsequent total joint arthroplasty (TJA) with and without previous bariatric surgery (BS). We performed a meta-analysis based on the current evidence-based study to determine the influences of prior BS on the short-term and long-term outcomes following TJA.

Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty

BackgroundThe incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship.MethodsThis is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts.ResultsA total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001).ConclusionDepression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.     

Financial Distress and Discussing the Cost of Total Joint Arthroplasty

Background

Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.

An Overview of Telehealth in Total Joint Arthroplasty

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians’ ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.     

Factors Associated With Early Return to Driving Following Total Joint Arthroplasty

BackgroundPatients often ask when they can safely return to driving a car following total joint arthroplasty (TJA). Most prior research has relied on driving simulators. Our study sought to learn more about real-world patient experiences in returning to driving after total knee arthroplasty (TKA) or total hip arthroplasty (THA).MethodsOur institutional total joint registry was used to identify living patients aged 18-85 who underwent primary TKA or primary THA for a primary diagnosis of osteoarthritis between January 1, 2019 and December 31, 2019. Patients who had undergone multiple TJA operations in 2019 or had a primary mailing address outside of the United States were excluded. Ultimately 2508 eligible TJA patients received a survey by mail.ResultsA total of 1128 of 2508 eligible patients (45%) completed surveys and returned them by mail. After 121 surveys were discarded for incompletion, inconsistency, or limited preoperative driving volume, 1007 patients were included in our study. Among these patients, 99% returned to driving postoperatively, with 23% returning within 2 weeks, and 88% returning within 6 weeks. Factors associated with the odds of a patient returning to driving within 2 weeks included laterality, gender, postoperative confidence, postoperative comfort, and surgeon advice. Ten patients (1%) have been involved in a car accident postoperatively.ConclusionAlmost all patients returned to driving postoperatively without being involved in a car accident. Gender, laterality, patient confidence, and comfort as well as surgeon advice were significantly associated with the odds of a patient returning to driving within 2 weeks postoperatively.     

Changes in Patient Satisfaction Following Total Joint Arthroplasty

BackgroundThe primary aim is to identify the degree to which patient satisfaction with the outcome of total hip arthroplasty (THA) or total knee arthroplasty (TKA) changes between 1 and 3 years from the procedure. The secondary aim is to identify variables associated with satisfaction.MethodsData were sourced from 2 prospective international, multicenter studies (919 THA and 450 TKA patients). Satisfaction was assessed by a 10-point numerical rating scale, at 1- and 3-year follow-up. Linear mixed-effects models were used to assess factors associated with satisfaction.ResultsFor the THA cohort, higher preoperative joint space width (odds ratio [OR] = 0.28; P = .004), pain from other joints (OR = 0.26; P = .033), and lower preoperative health state (OR = −0.02; P < .001) were associated with consistently lower levels of satisfaction. The model also showed that patients with preoperative anxiety/depression improved in satisfaction between 1 and 3 years (OR = −0.26; P = .031).For the TKA cohort, anterior (vs neutral or posterior) tibial component slope (OR = 0.90; P = .008), greater femoral component valgus angle (OR = 0.05; P = .012), less severe osteoarthritis (OR = −0.10; P < .001), and lower preoperative health state (OR = −0.02; P = .003) were associated with lower levels of satisfaction across the study period. In addition, patients with anterior tibial component slope improved in satisfaction level over time (OR = −0.33; P = .022).ConclusionChanges in satisfaction following THA and TKA are rare between 1- and 3-year follow-up. The findings of this study can be used to guide patient counseling preoperatively and to determine intervals of routine follow-up postoperatively.     

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion

Background

Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).

Optimal Length of Stay Following Total Joint Arthroplasty to Reduce Readmission Rates

BackgroundLength of stay (LOS) following total joint arthroplasty (TJA) continues to decrease. The effects of this trend on readmission risk and total cost are unclear. We hypothesize that optimal LOS following TJA minimizes index hospitalization, early readmission risk, and total cost.MethodsRetrospective data from the South Carolina Department of Revenue and Fiscal Affairs was reviewed for patients who underwent primary TJA in South Carolina from 2000 to 2015 (n = 172,760). Data for readmissions within 90 days were included. Severity of illness was estimated by Elixhauser score (EH). Index LOS is defined as the surgery and the subsequent hospital stay.ResultsPatients with more significant medical comorbidities (EH ≥ 4) had significantly longer LOS than healthier patients (4.0 vs 3.4 days, P < .001). Independent of EH, readmitted patients had a significantly longer index LOS than those never readmitted (4.3 vs 3.6 days, P < .001). For healthier patients (EH ≤ 3), each additional inpatient day increased readmission risk, while among sicker patients, staying 2 days vs 1 day was protective against readmission risk. Since 2000, the total index cost of TJA has doubled and average cost per inpatient day has tripled, but readmission rates remain essentially unchanged (7.4% to 7.0%).ConclusionIncreased LOS was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal LOS after TJA is highly influenced by the patient’s overall health. Despite a 300% increase in TJA daily cost, readmission rate has changed minimally over the last 15 years.     

The Evaluation of Comorbidities Relative to Length of Stay for Total Joint Arthroplasty Patients

Background

The ability to identify those at risk for longer inpatient stay helps providers with postoperative planning and patient expectations. Decreasing length of stay (LOS) in the future will be determined by appropriate patient selection, risk stratification, and preoperative patient optimization. The purpose of this study was to identify factors that place patients at risk for extended postoperative LOSs.

Relative Contribution of Outpatient Arthroplasty Risk Assessment Score Medical Comorbidities to Same-Day Discharge After Primary Total Joint Arthroplasty

BackgroundSelection of patients who can safely undergo outpatient total joint arthroplasty (TJA) is an increasing priority given the growth of ambulatory TJA. This study quantified the relative contribution and weight of 52 medical comorbidities comprising the Outpatient Arthroplasty Risk Assessment (OARA) score as predictors of safe same-day discharge (SDD).MethodsThe medical records of 2748 primary TJAs consecutively performed between 2014 and 2020 were reviewed to record the presence or absence of medical comorbidities in the OARA score. After controlling for patients not offered SDD due to OARA scores and patients who were offered but declined SDD, the final analysis sample consisted of 631 cases, 92.1% of whom achieved SDD and 7.9% of whom did not achieve SDD. Odds ratios were calculated to quantify the extent to which each comorbidity is associated with achieving SDD.ResultsDemographic characteristics of analysis cases were consistent with a high-volume TJA practice in a US metropolitan area. Among testable OARA comorbidities, 53% significantly decreased the likelihood of SDD by 2.3 (body mass index [BMI] ≥40 kg/m²) to 12 (history of post-operative confusion and pacemaker dependence) times. BMI between 30 and 39 kg/m² did not affect the likelihood of SDD (P = .960), and BMI ≥40 kg/m² had the smallest odds ratio in our study (2.28, 95% confidence interval 1.11-4.67, P = .025).ConclusionStudy findings contribute to the refinement of the OARA score as a successful predictor of safe SDD following primary TJA while maintaining low 90-day readmission rates.     

Operative Time Affects Short-Term Complications in Total Joint Arthroplasty

Background

Increased operative time has been associated with increased complications after total joint arthroplasty (TJA). The purpose of the present study was to investigate the effect of operative time on short-term complications after TJA while also identifying patient and operative factors associated with prolonged operative times.

Surgeon Decision-Making for Individuals With Obesity When Indicating Total Joint Arthroplasty

BackgroundObesity is a risk factor for complications after total joint arthroplasty (TJA). This study analyzed the impact of individual surgeon demographics, financial concerns, and other factors in determining patient candidacy for TJA based on body mass index (BMI).MethodsA 21-question survey was approved by the American Association of Hip and Knee Surgeons Research Committee for distribution to its membership. Objective questions asked about surgeon or hospital BMI thresholds for offering TJA. Subjective questions asked about physician comfort discussing topics including obesity, bariatric surgery, and weight loss before TJA, as well as insurance and age considerations.ResultsFor TJA procedures, 49.9% of surgeons had a BMI cutoff at 40, 24.5% at 45, and 8.3% at 50. At a BMI cutoff of 40, 23.8% of surgeons felt their patient volume would be adversely affected, whereas at a BMI cutoff of 35, 50% of surgeons felt their patient volume would be adversely affected. Surgeons were more likely to not perform total hip arthroplasty on patients with morbid obesity than total knee arthroplasty (P = .037). Significantly more academic surgeons did not have cutoffs for total hip arthroplasty (P = .003) or total knee arthroplasty (P < .001) compared with all other practice settings.ConclusionThere are myriad factors that affect surgeon BMI thresholds for offering elective TJA including poor outcomes, hospital thresholds, financial considerations, and the well being of the patient. Further work should be performed to minimize the risks associated with TJA while providing the best possible care to patients with morbid obesity.     

Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty

BackgroundThe Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature.MethodsWe prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff.ResultsAlthough the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes.ConclusionSurgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.     

Outcome and Predictors of Septic Failure Following Total Joint Arthroplasty for Prior Septic Arthritis of Hip and Knee Joint

BackgroundArthroplasty patients with prior septic arthritis are at a high risk of developing periprosthetic joint infection (PJI). The aims of this study are to investigate the outcome and predictors of septic failure following total joint arthroplasty (TJA) for prior septic arthritis. In addition, the optimal timing of TJA is also discussed.MethodsA retrospective review of 105 TJA patients with prior septic arthritis between January 2000 and December 2019 was performed. Patient-specific and surgery-related factors, organism profiles, and other relevant variables were recorded.ResultsAt a mean follow-up of 10.3 years, the PJI rate was 16.2%. The adjusted Cox proportional hazards model showed that male gender (HR, 9.95; P < .01), end-stage renal disease (HR, 37.34; P < .01), debridement surgery ≥3 times (HR,4.75; P = .04) and polymicrobial infection in primary septic arthritis (HR, 10.02; P = .02) were independent risk factors for PJI. Neither the types of initial debridement, nor one-stage vs two-stage arthroplasty was related to the risk of PJI. While delaying the timing of TJA did not correlate with a reduction of PJI rate, there was a higher risk of PJI re-infection by the same microorganisms isolated in prior septic arthritis if TJA was performed within 6 months after septic arthritis.ConclusionsOur study demonstrated that male gender, end-stage renal disease (ESRD), multiple debridement surgeries and polymicrobial septic arthritis predisposed septic failure of TJA following prior septic arthritis. Surgeons should counsel patients with the potential complications, and be cognizant about the risk factors pertaining to septic failure when considering TJA.     

The Risk Assessment and Prediction Tool Is Less Accurate in Extended Length of Stay Patients Following Total Joint Arthroplasty

Background

Although preoperative risk assessment tools have been effective in predicting discharge disposition after total joint arthroplasty (TJA), studies reporting on discharge planning in extended length of stay (ELOS), >3 days, patients are lacking. The purpose of this study was to describe the predictive utility of the Risk Assessment and Prediction Tool (RAPT) for discharge disposition in ELOS patients.