Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital

Background

Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.

Impact of Compensated Cirrhosis Etiology on Postoperative Outcomes Following Total Knee Arthroplasty

BackgroundCirrhotics often demonstrate worse outcomes than their non-cirrhotic counterparts following orthopedic surgery; however, there are limited arthroplasty-focused data on this occurrence. Additionally, variances in postoperative outcomes among the different etiologies of cirrhosis have not been well described. The aim of this study is to evaluate the effect compensated cirrhosis had on postoperative outcomes following elective total knee arthroplasty (TKA).MethodsIn total, 1,734,568 patients who underwent primary TKA from 2006 to 2013 were identified using the Medicare Claims Database. Patients were divided into those with a history of compensated cirrhosis and those with no history of liver disease. Subgroup analysis was performed based on the etiology of cirrhosis. Multivariate logistic regression was used to evaluate postsurgical outcomes of interest.ResultsCirrhotic patients had higher risk of developing disseminated intravascular coagulation (odds ratio [OR] 2.76, P = .003), encephalopathy (OR 3.00, P < .001), and periprosthetic infection (OR 1.79, P < .001) compared to controls. Following subgroup analysis, alcoholic cirrhotics had high risk of periprosthetic infection (OR 2.12, P < .001), fracture (OR 3.28, P < .001), transfusion (OR 2.45, P < .001), and encephalopathy (OR 7.34, P < .001) compared to controls. Viral cirrhosis was associated with an increase in 90-day charges ($14,941, P < .001) compared to controls, while cirrhosis secondary to other causes was associated with few adverse outcomes compared to controls.ConclusionLiver cirrhosis is an independent risk factor for increased perioperative morbidity and financial burden following TKA. Cirrhosis due to etiologies other than viral infections and alcoholism are associated with few adverse outcomes. Surgeons should be aware of these complications to properly optimize postoperative management.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.     

Same-Day Discharge Total Knee Arthroplasty in Octogenarians

BackgroundOne of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old.MethodsThis is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed.ResultsThirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days.ConclusionOctogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.     

Discharge to Inpatient Rehab Does Not Result in Improved Functional Outcomes Following Primary Total Knee Arthroplasty

Background

Monitored rehabilitation has long been considered an essential part of the recovery process in total knee arthroplasty (TKA). However, the optimal setting for rehabilitation remains uncertain. We sought to determine whether inpatient rehabilitation settings result in improved functional and patient-reported outcomes after primary TKA.

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty

BackgroundDevelopment of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including discharge to facilities and mortality. Few studies have identified modifiable risk factors or strategies that the surgeon may use to reduce this risk.MethodsWe identified all patients undergoing primary TJA at a single hospital from 2005 to 2017, and collected patient demographics, comorbidities, short-term outcomes, as well as perioperative laboratory results. We defined AKI as an increase in creatinine levels by 50% or 0.3 points. We compared demographics, comorbidities, and outcomes between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. A stochastic gradient boosting model was constructed to predict AKI.ResultsIn total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (95% confidence interval [CI] 0.14-0.38, P < .001), in-hospital complication risk (odds ratio = 1.73, 95% CI 1.45-2.07, P < .001), and discharge to facility risk (odds ratio = 1.26, 95% CI 1.05-1.53, P = .012). Forty-one predictive variables were included in the predictive model, with important potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered. The final predictive model demonstrated excellent performance with a c-statistic of 0.967.ConclusionOur results confirm that AKI has adverse effects on outcome metrics including length of stay, discharge, and complications. Although many risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss, such as through the use of tranexamic acid, may aid in mitigating this risk.     

Reasons and Risk Factors for Delayed Discharge After Total Knee Arthroplasty Using an Opioid-Sparing Discharge Protocol

BackgroundIn this study, we aimed to assess the length of hospital stay after total knee arthroplasty in a European healthcare setting. We also aimed to investigate risk factors and reasons for delayed discharge when using an opioid-sparing fast-track protocol.MethodsFrom our institutional database, we retrospectively identified all primary elective unilateral total knee arthroplasties performed during January to December 2015. Both patient-related and surgery-related variables were collected from our databases. Risk factors were analyzed using multivariable logistic regression analysis.ResultsThe median length of stay (LOS) was 3 days. Independent risk factors for delayed discharge were higher age, higher American Society of Anesthesiologists score, general anesthesia, surgery performed toward the end of the week, longer duration of surgery, longer stay in the post-anesthesia care unit, and shorter preoperative walking distance. The main reasons for delayed discharge were delayed functional recovery and pain.ConclusionThis study identified several independent risk factors for an LOS longer than 3 days. These risk factors add to the current knowledge on which patients have an increased risk of prolonged LOS, and which patients should be targeted when striving to further reduce the LOS.     

Cementless Total Knee Arthroplasty in Knee Osteonecrosis Demonstrated Excellent Survivorship and Outcomes at Three-Year Minimum Follow-Up

Background

Lack of consensus exists on the use of cementless total knee arthroplasty (TKA) in patients with knee osteonecrosis. Therefore, this study was conducted to evaluate (1) implant survivorship; (2) clinical outcomes and complications; and (3) radiographic outcomes of primary cementless TKA in knee osteonecrosis.

Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty

BackgroundAs ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence.MethodsPatients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression.ResultsThe most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD.ConclusionsThe most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.     

Risk Stratification and Pain Outcomes Following Revision Total Hip Arthroplasty for Adverse Local Tissue Reactions

BackgroundRevision total hip arthroplasty (THA) for adverse local tissue reactions (ALTRs) secondary to head-neck taper corrosion is associated with a high complication rate. Diagnosis of ALTR is based on risk stratification using the patient’s history and examination, implant risk, serum metal ion levels, and imaging. The purpose of this study was to determine if stratification using similar risk factors is predictive of outcomes following revision THA for metal-on-polyethylene (MoP) ALTR.MethodsWe performed a retrospective review on 141 patients revised for ALTR due to head-neck taper corrosion. Pain outcomes following surgery were analyzed using a generalized linear mixed model. Complications were defined as instability/dislocation, infection, fracture, nerve palsy, leg-length discrepancy, or reoperation.ResultsThe overall complication rate was 17.7%. The odds of having pain decreased by 44% after revision surgery (Odds Ratio = 0.56, 95% Confidence Interval: 0.324 to 0.952). There was no significant difference in instability/dislocation based on either increased or decreased head-neck offset (P = .67) or magnetic resonance imaging findings of abductor loss, effusion size, and degree of ALTR (P = .73). Increased serum cobalt (P = .31) and chromium (P = .08) levels did not predict complications; however, a decreased cobalt-chromium ratio was associated with postoperative complications (2.8 versus 3.5; P = .002).ConclusionThese findings are the first to suggest that patients who have ALTR after MoP THA undergoing revision surgery demonstrated major pain relief. Increasing femoral head offset did not change rates of instability/dislocation. In clinical scenarios where preoperative cobalt-chromium femoral head offsets were greater than available ceramic head offsets, a mandatory decrease in femoral head offset did not increase rates of instability/dislocation.     

Incidence of and Risk Factors for 30-Day Readmission Following Elective Primary Total Joint Arthroplasty: Analysis From the ACS-NSQIP

Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and 8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age (P = 0.002), male gender (P = 0.03), cancer history (P = 0.008), elevated BUN (P = 0.002), a bleeding disorder (P < 0.001) and high ASA class (P < 0.001) as predictors of readmission. In THA, obesity (P = 0.008), steroid use (P = 0.037), a bleeding disorder (P = 0.002), dependent functional status (P = 0.022), and high ASA class (P < 0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification.     

Modifiable,Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

BackgroundWe sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events.MethodsData from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days.ResultsThe average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63).ConclusionThis study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.     

Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty

BackgroundThe aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA.MethodsPatients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the “LOA” cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA.ResultsIn total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the “LOA” cohort when compared to the “TKA Only” cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all).ConclusionIncidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA.Level of EvidenceIII, Retrospective Cohort Study.     

Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty

BackgroundRecent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA.MethodsThe Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis.ResultsOf the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points.ConclusionIn a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.     

Perioperative Outcomes and Complications in Patients With Heart Failure Following Total Knee Arthroplasty

Background

Heart failure (HF) is a common comorbidity in the aging population and they will require major elective surgery. The purpose of this study is to determine if HF is a risk factor for adverse perioperative outcomes and short-term complications following total knee arthroplasty.

The New Surgical Technique for Improving Total Knee and Hip Arthroplasty Outcomes: Patient Selection

Background

Inclusion of patient satisfaction scores in setting reimbursements has been suggested by health care policy makers to contain cost and improve outcomes. The Short Form 36 Health Survey (SF-36) score provides a health-related quality of life (HRQoL) measure of arthroplasty outcome. Although previous work identified factors that influence this score for hip and knee arthroplasty patients, they did not focus on how a surgeon might use this information in a clinical setting. The present study examined whether relatively simple criteria might identify patients more likely to experience minimal HRQoL improvement.

Results of Cemented vs Cementless Primary Total Knee Arthroplasty Using the Same Implant Design

Background

Although cemented total knee arthroplasty (TKA) continues to be the gold standard, there are patient populations with higher failure rates with cemented TKAs such as the obese, morbidly obese, and younger active males. Cementless TKA usage continues to increase because of the potential benefits of long-term biologic fixation similar to the rise in cementless total hip arthroplasty. The purpose of this study was to evaluate the clinical and radiographic results of cementless TKA using a novel highly porous cementless tibial baseplate.

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BackgroundIt is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.MethodsPatient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).ResultsOne hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.ConclusionThese results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.     

Predictive Risk Factors for 30-day Readmissions Following Primary Total Joint Arthroplasty and Modification of Patient Management

The Centers for Medicare and Medicaid have begun to publically publish statistics on readmissions following primary total hip (THA) and total knee arthroplasty (TKA). Our study retrospectively assesses 30-day readmissions rates following THA and TKA, performed by a single surgeon at a tertiary care medical center between 2007 and 2012. Results of a univariate analysis and logistic regression model indicated female gender, high ASA class, and increased operative time to be significantly associated with higher rates of readmission (OR 4.646, OR 1.257, and OR 5.323, respectively). Readmissions most often occurred within the first week of patient discharge. Surgical complications and gastrointestinal discomfort were the most common causes for readmission. Using readmission risk we can stratify patients into tiered critical care pathways to reduce readmissions.     

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty

BackgroundRecently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA.MethodsPatients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours.ResultsA total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours.ConclusionThis study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.