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.     

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.     

Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty

BackgroundThe benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF.MethodsData from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities.ResultsCompared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001).ConclusionAmong Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.     

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.     

A Nationwide Analysis on the Impact of Schizophrenia Following Primary Total Knee Arthroplasty: A Matched-Control Analysis of 49,176 Medicare Patients

BackgroundThe influence of schizophrenia on total knee arthroplasty (TKA) is limited in the literature. Therefore, the purpose of this study was to investigate whether patients with schizophrenia undergoing primary TKA have (1) longer in-hospital length of stay (LOS); (2) higher readmission rates; (3) higher medical complications; (4) higher implant-related complications; and (5) higher costs of care compared to controls.MethodsPatients with schizophrenia undergoing primary TKA were identified within the Medicare claims database. The study group was randomly matched in a 1:5 ratio to controls according to age, sex, and medical comorbidities. The query yielded 49,176 patients with (n = 8,196) and without (n = 40,980) schizophrenia undergoing primary TKA. Primary outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to day of surgery and 90-day costs of care. A P-value less than .01 was considered statistically significant.ResultsSchizophrenia patients had longer in-hospital LOS (3.73 days vs 3.22 days, P < .0001) and had higher incidence and odds ratios (ORs) of readmission rates (18.26 vs 12.07%; OR: 1.58, P < .0001) compared to controls. Schizophrenia patients had higher incidence and odds of medical (3.23 vs 1.10%; OR: 2.99, P < .0001) and implant-related complications (5.92 vs 3.59%; OR: 1.68, P < .0001) and incurred significantly higher day of surgery ($13,300.58 vs $11,681.77, P < .0001) and 90-day costs of care ($18,222.18 vs $14,845.64, P < .0001).ConclusionThis study demonstrates that patients with schizophrenia have longer in-hospital LOS, higher readmission rates, higher complications, and increased costs of care after primary TKA.     

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.     

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.     

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.     

Iron Deficiency Anemia is Associated with Increased Early Postoperative Surgical and Medical Complications Following Total Hip Arthroplasty

BackgroundIron deficiency anemia (IDA) is a medical comorbidity commonly diagnosed in those undergoing primary total hip arthroplasty (THA). The authors sought to evaluate IDA as a risk factor for early postoperative complications following discharge and describe the hospital resource utilization of this patient population.MethodsPatients with a diagnosis of IDA who underwent THA from 2005 to 2014 were identified in a national insurance database. The rates of postoperative medical complications and surgery-related complications, as well as hospital readmission, emergency department visits, and death were calculated. Additionally, 90-day and day of surgery cost and length of stay were calculated. IDA patients were then compared to a 4:1 matched control population without IDA using a logistic regression analysis to control for confounding factors.ResultsIn total, 98,681 patients with a preoperative diagnosis of IDA who underwent THA were identified and compared to 386,724 controls. IDA was associated with increased risk of 30-day emergency department visits (odds ratio [OR] 1.35, P < .001) and 30-day readmission (OR 1.49, P < .001). IDA was also associated with an increased 90-day medical complication rate (cerebrovascular accident OR 1.11, P = .003; urinary tract infection OR 1.14, P < .001; acute renal failure OR 1.24, P < .001; transfusion OR 1.40, P < .001), as well as 1-year periprosthetic joint infection (OR 1.27, P < .001), revision (OR 1.22, P < .001), dislocation (OR 1.25, P < .001), and fracture (OR 1.43, P < .001). Patients with IDA accrued higher hospital charges ($27,658.27 vs $16,709.18, P < .001) and lower hospital reimbursement ($5509.90 vs $3605.59, P < .001).ConclusionPatients with preoperative IDA undergoing THA are at greater risk of experiencing early postoperative complications and have greater utilization of hospital resources.     

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.     

Inflammatory Arthritis Is a Risk Factor for Multiple Complications After Total Hip Arthroplasty: A Population-Based Comparative Study of 68,348 Patients

BackgroundPatients with inflammatory arthritis (IA) are likely at higher risk of postoperative complications following total hip arthroplasty (THA), from the underlying disease, the degree of articular deformity, and immunosuppressive medications. The purpose of this study was to perform a comparative study of the risk of complications after THA between IA and osteoarthritis.MethodsA national private insurance database was used to select patients undergoing unilateral primary THA. Patients were categorized to the inflammatory cohort if they had a diagnosis of IA and treatment with an IA-specific medication within the year before surgery. Patients with no diagnosis of IA were considered osteoarthritis. Risk of Centers for Medicare and Medicaid Services–reportable complications and 90-day readmission was compared between cohorts using multivariate logistic regression controlling for age, gender, length of stay, comorbidities, and corticosteroid use.ResultsA total of 68,348 patients were included; 2.12% met criteria for IA. Patients with IA were found to have higher risk of transfusion (odds ratio [OR], 1.29; P < .01), mechanical complications (OR, 1.35; P = .01), infection (OR, 1.96; P < .01), and 90-day readmission (OR, 1.35; P < .01). There were no differences in risk of venous thromboembolism or medical complications.ConclusionPatients with IA have significantly higher risk of transfusion, mechanical complications, infection, and readmission following THA. Efforts should be made to optimize their health and medications before THA to minimize their complication risk. Additionally, hospitals should receive commensurate resources to maintain access to THA for patients with IA who are prone to higher resource utilization.Level of EvidenceIII.     

Recent Increases in Outpatient Total Hip Arthroplasty Have Not Increased Early Complications

BackgroundOutpatient total hip arthroplasty (THA) has increased in recent years. Recent regulatory changes may allow and incentivize outpatient THA in more patients; however, there are concerns regarding safety. The purpose of this study is to assess early complications in outpatient THA compared to longer hospitalization.MethodsWe identified patients undergoing primary THA in the National Surgical Quality Improvement Program database between 2015 and 2018. Patients were stratified by length of stay (LOS): 0 days (LOS 0), 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Multivariate analysis was performed.ResultsIn total, 4813 (4%) patients underwent outpatient THA, 84,627 (64%) had LOS of 1-2 days, and 42,293 (32%) had LOS ≥3 days. LOS 0 patients were younger, had lower body mass index, and less medical comorbidities compared to those with postsurgical hospitalization. Any complication was experienced in 3.2% of the LOS 0 group, 5.3% of the LOS 1-2 group, and 15.6% for the LOS ≥3 group (P < .0001). Readmission rates were 1.6%, 2.6%, and 4.7% for the 3 groups, respectively (P < .0001). After controlling for confounding variables, patients with LOS 1-2 days had higher odds for any complication (odds ratio 1.56 [1.32-1.83) and readmission (odds ratio 1.41 [1.12-1.78]) compared to LOS 0 days. Patients with LOS ≥3 days had higher odds for complications compared to LOS 0 or 1-2 days.ConclusionOutpatient THA had lower odds for readmission or complications compared to LOS 1-2 days. Despite increased outpatient surgery, many patients had postsurgical hospitalization and, due to patient factors, this remains an integral patient of post-THA care.     

Thirty-Day Complications in Osteonecrosis Patients Following Total Hip Arthroplasty

BackgroundThirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors.MethodsUsing the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson’s chi-square and Student t-tests.ResultsThe proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P < .001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors.ConclusionThis is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.     

Etiology and Complications of Early Aseptic Revision Total Hip Arthroplasty Within 90 Days

BackgroundThe etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.MethodsA national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.ResultsFour hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).ConclusionEarly aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.Level of EvidenceLevel III.     

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.     

High Bundled Payment Costs Following Total Hip and Knee Arthroplasty in African Americans

BackgroundConcerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients.MethodsWe queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs.ResultsCompared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001).ConclusionAfrican American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.     

The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols

BackgroundCompared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol.MethodsThis is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA.ResultsPatients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034).ConclusionNA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities.Level Of EvidenceLevel III Retrospective Cohort Study.     

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.     

Does Hemophilia Increase Risk of Adverse Outcomes Following Total Hip and Knee Arthroplasty? A Propensity Score–Matched Analysis of a Nationwide,Population-Based Study

BackgroundEnd-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA.MethodsThis retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1:4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital.ResultsAfter propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval [CI] = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P < .001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups.ConclusionHemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA.     

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BackgroundThe aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.MethodsIn total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.ResultsCirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls—other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.ConclusionCirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.