The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental?

BackgroundWhether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex.MethodsThis is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts.ResultsThere was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002).ConclusionFrailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.     

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BackgroundTo determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.MethodsRetrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.ResultsThe cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).ConclusionThe LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient’s first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.Level of EvidenceLevel 3-retrospective cohort study.     

The Impact of Pre-Operative Healthcare Utilization on Complications,Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty

BackgroundIdentifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized.MethodsThis is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU.ResultsThe 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events.ConclusionPatients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU.Level of EvidenceLevel III.     

What Are Drivers of Readmission for Readmission-Requiring Venous Thromboembolic Events After Primary Total Hip Arthroplasty? An Analysis of 544,443 Cases

BackgroundVenous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission.MethodsThe Agency of Healthcare Research and Quality’s National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities.ResultsHigher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05).ConclusionOne in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE 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.     

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study

BackgroundAs the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes.MethodsIn this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression.ResultsIn total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001).ConclusionTHA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.     

Early Discharge After Total Hip and Knee Arthroplasty—An Observational Cohort Study Evaluating Safety in 330,000 Patients

BackgroundThere has been considerable interest in recent years for early discharge after arthroplasty. We endeavored to evaluate the safety of same-day discharge given the rapid uptake of this practice approach.MethodsThis is a retrospective observational cohort study of the American College of Surgeons National Surgical Quality Improvement Program registry database. We included patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2015 and 2018. We categorized length of stay (LOS) as same-day discharge (LOS = 0 days), accelerated discharge (LOS = 1 day), and routine discharge (LOS = 2-3 days). For each LOS cohort, we determined the incidence of major complications within 30 days (surgical site infection [SSI], reoperation, readmission, deep vein thrombosis [DVT], and PE) and evaluated risk using multivariate logistic regression analysis if incidence was >1%. Patients undergoing THA and TKA were evaluated independently.ResultsThe final study cohort consisted of 333,212 patients, including 124,150 who underwent THA (37%) and 209,062 who had TKA (63%). In the THA same-day discharge cohort, the incidence of superficial SSI (0.2%), deep/organ space SSI (0.3%), DVT (0.2%), and PE (0.2%) was low. The risk of reoperation was comparable to routine discharge (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.09; P = .17) and readmission rate was significantly lower (OR, 0.60; 95% CI, 0.48-0.76; P < .001). The risk of reoperation and readmission was also lower in the accelerated discharge cohort compared to routine discharge. In the TKA same-day discharge cohort, the risk of superficial SSI (0.3%), deep/organ space SSI (0.3%), reoperation (0.8%), DVT (0.4%), and PE (0.5%) was low. The risk of readmission after same-day discharge was comparable to routine discharge (OR, 0.85; 95% CI, 0.71-1.01; P = .07). In the accelerated discharge cohort, there was a small reduction in readmission risk (OR, 0.87; 95% CI, 0.81-0.93; P < .001).ConclusionThis large, observational, real-world study suggests that same-day and accelerated discharge management is safe clinical practice for patients undergoing total joint arthroplasty, yielding a similar risk of major acute 30-day complications. Further clinical trials evaluating long-term major outcomes, including patient-reported outcomes and experiences, would offer further and definitive insight into this practice approach.     

The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty

BackgroundFrailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically.ResultsA total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001).ConclusionChronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.     

Effect of Sickle Cell Trait on Total Hip Arthroplasty in a Matched Cohort

BackgroundIt is unclear if sickle cell trait (SCT) carrier status conveys an increased risk for poor outcomes following total hip arthroplasty (THA). The purpose of this study is to compare short-term clinical outcomes of THA for patients with SCT vs matched controls.MethodsPatient records were queried from the PearlDiver database using International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. Patients with SCT who underwent THA were matched 1:1 with controls across age, gender, Elixhauser Comorbidity Index, obesity, and US region. Thirty-day and 90-day rates of systemic complications and 1-year and 2-year rates of joint complications were compared with logistic regression.ResultsIn total, 1646 patients were assigned to each cohort. In the 30-day and 90-day postoperative periods, SCT carriers had a higher likelihood of cerebrovascular accident, anemia, acute renal failure, pneumonia, sepsis, deep vein thrombosis, pulmonary embolism, and respiratory failure (all P < .05). SCT carriers exhibited significantly higher risk of periprosthetic joint infection at both 1 (3.5% vs 2.1%; odds ratio [OR] 1.91, 95% confidence interval [CI] 1.22-2.99) and 2 years (3.7% vs 2.6%; OR 1.63, 95% CI 1.07-2.49) postoperatively. Prosthetic loosening was also significantly more likely for SCT carriers within 1 year (1.3% vs 0.3%; OR 4.49, 95% CI 1.75-13.86).ConclusionPatients with SCT exhibited significantly higher risk for systemic complications, periprosthetic joint infection, and prosthetic loosening after THA. Increased perioperative efforts should be made to prevent hypoxia, acidosis, and dehydration, as these states increase red blood cell sickling, which may reduce complication rates and improve outcomes in patients with SCT.     

Effects of a Total Knee Arthroplasty Care Pathway on Cost,Quality, and Patient Experience: Toward Measuring the Triple Aim

BackgroundCare pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience.MethodsA historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.ResultsIn total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (?8.501%, 95% confidence interval [CI] ?9.639 to ?7.350), a decrease in LOS (?26.966%, 95% CI ?28.516 to ?25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient.ConclusionTKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.     

Tranexamic Acid is Associated With Decreasing the Risk of Complications in Patients Undergoing Arthroplasty With Preoperative Coagulopathy

BackgroundPreoperative coagulopathy is a risk factor for perioperative blood loss. The antifibrinolytic effects of tranexamic acid (TXA) could negate the association between preoperative coagulopathy and adverse outcomes in patients undergoing total joint arthroplasty (TJA). However, no studies have evaluated this relationship. This study compared the perioperative outcomes of coagulopathic patients undergoing TJA who did and did not receive TXA.MethodsWe retrospectively reviewed 2123 primary TJAs (975 knees and 1148 hips) performed in patients with a preoperative coagulopathy. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/μL. TXA was administered in 240 patients and not administered in 1883 patients. Demographics, comorbidities, and surgical details including operative time, blood loss, and thromboprophylaxis agent were recorded. Multivariate regression was used to identify factors associated with 90-day outcomes.ResultsPatients who received TXA had less intraoperative blood loss and 2.3 times decreased risk of 90-day complications (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20-0.85, P = .021), especially cardiovascular (2.92% vs 12.1%, P <.001) and wound complications (0.0% vs 1.59%, P = .042). TXA was also associated with shorter length of stay (beta 0.74, 95% CI 0.67-0.82, P <.001) and decreased risk of nonhome discharge (OR 0.50, 95% CI 0.29-0.83, P = .009). There was no difference in mortality or 90-day readmissions between the groups.ConclusionTXA administration decreased the incidence of perioperative complications and resource utilization in patients undergoing arthroplasty with a preoperative coagulopathy identified on preadmission testing. These findings support the broader adoption of TXA in patients undergoing TJA, particularly when the patient has a preoperative coagulopathy.     

Association Between Nonsurgical Weight Loss From Body Mass Index >40 to Body Mass Index <40 and Complications and Readmissions Following Total Hip Arthroplasty

BackgroundElevated body mass index (BMI) is a risk factor for adverse outcomes following total hip arthroplasty (THA). It is unknown if preoperative weight loss to a BMI <40 kg/m² is associated with reduced risk of adverse outcomes.MethodsWe retrospectively reviewed elective, primary THA performed at an academic center from 2015 to 2019. Patients were split into groups based on their BMI trajectory prior to THA: BMI consistently <40 (“BMI <40”); BMI >40 at the time of surgery (“BMI >40”); and BMI >40 within 2 years preoperatively, but <40 at the time of surgery (“Weight Loss”). Length of stay (LOS), 30-day readmissions, and complications as defined by Centers for Medicare and Medicaid Services were compared between groups using parsimonious regression models and Fisher’s exact testing. Adjusted analyses controlled for sex, age, and American Society of Anesthesiologists class.ResultsIn total, 1589 patients were included (BMI <40: 1387, BMI >40: 96, Weight Loss: 106). The rate of complications in each group was 3.5%, 6.3%, and 8.5% and the rate of 30-day readmissions was 3.0%, 4.2%, and 7.5%, respectively. Compared to the BMI <40 group, the weight loss group had a significantly higher risk of 30-day readmission (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.19-6.17, P = .02), higher risk of any complication (OR 2.47, 95% CI 1.09-5.59, P = .03), higher risk of mechanical complications (OR 3.07, 95% CI 1.14-8.25, P = .03), and longer median LOS (16% increase, P = .002). The BMI >40 group had increased median LOS (10% increase, P = .03), but no difference in readmission or complications (P > .05) compared to BMI <40.ConclusionWeight loss from BMI >40 to BMI <40 prior to THA was associated with increased risk of readmission and complications compared to BMI <40, whereas BMI >40 was not.Level of evidenceLevel III – Retrospective Cohort Study.     

Population-based analysis of salvage radical prostatectomy with examination of factors associated with adverse perioperative outcomes

IntroductionSalvage radical prostatectomy (SRP) is a potentially curative operation performed for recurrent prostate cancer after radiation therapy (RT). The purpose of this study was to examine perioperative and pathologic outcomes of SRP in a national cohort.Materials and methodsThe National Cancer Database from 1998 to 2011 was used to identify 408 patients who underwent SRP. We evaluated the demographic data, clinical variables, and pathologic and perioperative outcomes. Primary outcomes of interest were length of stay (LOS) and positive surgical margins (PSM). A multivariable logistic regression model was employed to identify preoperative predictors of LOS ≥3 days and PSM following SRP.ResultsAmong patients undergoing SRP, the mean age was 62.5±6.8 years, mean prostate-specific antigen (PSA) level was 12.6±15.6 ng/ml, and 64% were categorized as clinical stage T1. External beam RT (89%), followed by brachytherapy (11%), was the most common modalities for primary RT. Most SRPs were performed at high-volume centers (57%) in metropolitan locations (83%). Most patients underwent a lymph node dissection (75%) and the mean node count was 15.0±30.1. On final pathology, 73% had intermediate- or high-grade disease (Gleason score 7 in 43% and Gleason score 8–10 in 30%), 49% had pT3 or pT4 disease, 6.2% had positive lymph nodes, and 34% had PSM. The mean LOS was 3.5±9.9 days, and 43% of patients had a LOS≥3 days. The 30-day readmission rate was 6.5% after SRP, and 30- and 90-day postoperative mortality rates were extremely low at 0.4% (n = 1). On multivariable analysis of the entire cohort, PSA level>20 ng/ml was an independent predictor of PSM (OR = 3.68, 95% CI: 1.2–10.9, P = 0.018). PSA level>20 ng/ml (OR = 4.37, 95% CI: 1.2–16.2, P = 0.027) and cT2 or greater disease (OR = 2.52, 95% CI: 1.0–6.2, P = 0.046) were associated with prolonged LOS (LOS≥3 d), whereas surgery at an academic facility (OR = 0.30, 95% CI: 0.1–0.8, P = 0.02) reduced the odds of LOS≥3 days.ConclusionsIn select patients derived from a population-based cohort, SRP results in effective local cancer control with acceptable perioperative outcomes. PSA level>20 ng/ml is independently associated with PSM and prolonged LOS after SRP. Clinical stage T2 or greater disease is also associated with prolonged LOS, whereas surgery at an academic facility reduced this risk.     

Frailty,Race/Ethnicity,Functional Status,and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

BackgroundAlthough frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.MethodsThe National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.ResultsWe identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.ConclusionDisparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.     

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

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

Sodium Abnormalities Are an Independent Predictor of Complications in Total Joint Arthroplasty: A Cautionary Tale!

BackgroundElectrolyte levels are commonly obtained as part of the preoperative workup for total joint arthroplasty, but limited information exists on the interplay between electrolyte abnormalities and outcomes.MethodsThe National Surgical Quality Improvement Program was queried for primary, elective total hip arthroplasty and total knee arthroplasty (THA, TKA) performed between 2011 and 2017. Three patient groups were compared: normal (control), hypernatremia, and hyponatremia. The primary outcomes were length of stay (LOS) and 30-day adverse events: complications, readmissions, reoperations, and mortality.ResultsA total of 244,538 TKAs and 145,134 THAs were analyzed. The prevalence of hyponatremia and hypernatremia was 6.9% and 1.0%, respectively. After controlling for any baseline differences, hypernatremia was an independent predictor of ventilation >48 hours (THA, odds ratio [OR] 3.53), unplanned intubation (THA, OR 3.14), cardiac arrest (THA, OR 2.42), pneumonia (THA, OR 2.16), Clostridium difficile infection (OR 4.66 and 3.25 for THA and TKA, respectively), LOS >2 days (THA, OR 1.16), and mortality (THA, OR 4.69). Similarly, hyponatremia was an independent predictor of LOS >2 days (TKA, OR 1.21), readmission (TKA, OR 1.40), reoperation (OR 1.32 and 1.47 for THA and TKA, respectively), surgical site infections (OR 1.39 and 1.54 for THA and TKA, respectively), and transfusion (OR 1.13 and 1.20 for THA and TKA, respectively).ConclusionAs the focus of total joint arthroplasty continues to shift toward value-based payment models and outpatient surgery, caution should be exercised in patients with abnormal preoperative sodium levels, particularly hypernatremia, because of significantly increased risk of prolonged LOS and 30-day adverse events.     

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BackgroundFalls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA.MethodsWe queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05.ResultsPatients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts.ConclusionFalls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation.Level of EvidenceIII.