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.     

Revision Joint Arthroplasty and Renal Transplant: A Matched Control Cohort Study

BackgroundThere is little literature concerning clinical outcomes following revision joint arthroplasty in solid organ transplant recipients. The aims of this study are to (1) analyze postoperative outcomes and mortality following revision hip and knee arthroplasty in renal transplant recipients (RTRs) compared to non-RTRs and (2) characterize common indications and types of revision procedures among RTRs.MethodsA retrospective Medicare database review identified 1020 RTRs who underwent revision joint arthroplasty (359 revision total knee arthroplasty [TKA] and 661 revision total hip arthroplasty [THA]) from 2005 to 2014. RTRs were compared to their respective matched control groups of nontransplant revision arthroplasty patients for hospital length of stay, readmission, major medical complications, infections, septicemia, and mortality following revision.ResultsRenal transplantation was significantly associated with increased length of stay (6.12 ± 7.86 vs 4.33 ± 4.29, P < .001), septicemia (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.83-3.46; P < .001), and 1-year mortality (OR, 2.71; 95% CI, 1.51-4.53; P < .001) following revision TKA. Among revision THA patients, RTR status was associated with increased hospital readmission (OR, 1.23; 95% CI, 1.03-1.47; P = .023), septicemia (OR, 1.82; 95% CI, 1.41-2.34; P < .001), and 1-year mortality (OR, 2.65; 95% CI, 1.88-3.66; P < .001). The most frequent primary diagnoses associated with revision TKA and THA among RTRs were mechanical complications of prosthetic implant.ConclusionPrior renal transplantation among revision joint arthroplasty patients is associated with increased morbidity and mortality when compared to nontransplant recipients.     

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis

BackgroundPatients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized.MethodsThe PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts.ResultsIn total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001).ConclusionCompared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA.Level of EvidenceLevel III.     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.     

Changes in Patient Satisfaction Following Total Joint Arthroplasty

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

Underweight Patients are at Increased Risk for Complications following Total Hip Arthroplasty

BackgroundGiven the prevalence of obesity in the United States, much of the adult reconstruction literature focuses on the effects of obesity and morbid obesity. However, there is little published data on the effect of being underweight on postoperative outcomes. This study aimed to examine the risk of low body mass index (BMI) on complications after total hip arthroplasty (THA).MethodsA large national database was queried between 2010 and 2020 to identify patients who had THAs. Using International Classification of Disease codes, patients were grouped into the following BMI categories: morbid obesity (BMI>40), obesity (BMI 30 to 40), normal BMI (BMI 20 to 30), and underweight (BMI<20). There were 58,151 patients identified, including 2,484 (4.27%) underweight patients, 34,710 (59.69%) obese patients, and 20,957 (36.04%) morbidly obese patients. Control groups were created for each study group, matching for age, sex, and a comorbidity index. Complications that occurred within 1 year postoperatively were isolated. Subanalyses were performed to compare complications between underweight and obese patients. Statistical analyses were performed using Pearson Chi-squares.ResultsCompared to their matched control group, underweight patients showed increased odds of THA revision (Odds Ratio (OR) = 1.32, P = .04), sepsis (OR = 1.51, P = .01), and periprosthetic fractures (OR = 1.63, P = .01). When directly comparing underweight and obese patients (BMI 30 and above), underweight patients had higher odds of aseptic loosening (OR = 1.62, P = .03), sepsis (OR = 1.34, P = .03), dislocation (OR = 1.84, P < .001), and periprosthetic fracture (OR = 1.46, P = .01).ConclusionMorbidly obese patients experience the highest odds of complications, although underweight patients also had elevated odds for several complications. Underweight patients are an under-recognized and understudied high risk arthroplasty cohort and further research is needed.     

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BackgroundThere has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.MethodsThe PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .ResultsAfter propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.ConclusionPatients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.     

Total Hip Arthroplasty in Patients With Cerebral Palsy: A Matched Comparison of 90-Day Adverse Events and 5-Year Implant Survival

BackgroundPeople with cerebral palsy (CP) may be considered for total hip arthroplasty (THA). However, short- and long-term outcomes after THA in this population remain poorly characterized.MethodsData from patients undergoing THA were abstracted from the 2010-2018 PearlDiver Mariner administrative database. Those with CP were matched to those without CP based on demographic and comorbid factors (1:4 matching). Ninety-day incidence of postoperative complications and hospital readmission was identified and compared. Five-year implant survival (based on need for revision) was also assessed and compared.Perioperative adverse events were then compared using multivariate logistic regression to adjust for any potential residual differences in demographic and comorbid factors after matching. Implant survival over time was compared with Kaplan-Meier plots with a log-rank test. Significance was set at P < .05 for all comparisons.ResultsIn total, 864 patients with CP were matched to 3448 patients without CP. After adjusting for differences in demographics and comorbidities, multivariate analyses demonstrated patients with CP had higher odds of urinary tract infection (odds ratio [OR] = 2.42, P = .007), pneumonia (OR = 3.77, P = .001), and periprosthetic fracture (OR = 2.55, P = .001). Rates of the other studied adverse events, including readmissions, were not significantly different between groups.At five years, 94.2% of the CP cohort and 95.2% of the non-CP cohort THAs remained unrevised (no difference by log rank, P = .195).ConclusionCompared with patients without CP, patients with CP undergoing THA were found to have higher odds of perioperative urinary tract infection, pneumonia, and periprosthetic fracture but not other perioperative complications or difference in five-year implant survival.     

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients.MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs.ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001).ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.     

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BackgroundHip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.MethodsPatients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.ResultsNonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.ConclusionConversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential “second hit” that both surgeons and patients should be aware of with initial decision-making.     

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score–Matched Cohort Analysis

BackgroundGeneral anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA.MethodsA large veteran’s database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 56,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics.ResultsUpon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients.ConclusionUsing a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.     

The Impact of Epilepsy on Complication Rates After Total Joint Arthroplasty: A Propensity Score–Matched Cohort Study

BackgroundIt is unclear how epilepsy may affect total joint arthroplasty outcomes. The purpose of this study is to analyze the impact of epilepsy on prosthesis-related complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsA retrospective cohort study was conducted using a national database. Patients who have epilepsy underwent a primary THA (n = 6,981) and TKA (n = 4,987) and were matched 1:4 (THA, n = 27,924; TKA, n = 19,948). Rates of low-energy falls and prosthesis-related complications within 2 years postoperatively were compared for patients who did and did not have epilepsy with multivariable logistic regression.ResultsAfter primary TKA, patients who have epilepsy exhibited significantly higher rates of aseptic revision (4.3% versus 3.5%, odds ratio [OR] 1.21, P = .017) and revision for prosthetic joint infection (1.8% versus 1.3%, OR 1.29, P = .041). THA patients who have epilepsy exhibited significantly higher rates of prosthetic dislocation (3.2% versus 1.9%, OR 1.54, P < .001), periprosthetic fracture (2.2% versus 0.8%, OR 2.39, P < .001), and aseptic loosening (1.7% versus 1.1%, OR 1.40, P = .002). Rates of low-energy falls within 2 years after TKA (14.1% versus 6.4%, OR 2.19, P < .001) and THA (33.6% versus 7.5%, OR 5.95, P < .001) were also significantly higher for patients who have epilepsy.ConclusionEpilepsy was associated with significantly higher rates of falls (P < .001) and prosthesis-related complications after primary THA (P < .05) and TKA (P < .05). Precautions should be implemented in this population during intraoperative and perioperative decision-making to reduce complication risk.Level of EvidenceLevel III.     

Safety and Efficacy of Rivaroxaban in Primary Total Hip and Knee Arthroplasty

BackgroundAn optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin.MethodsA large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin.ResultsAfter accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036).ConclusionRivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.     

Effects of chronic kidney disease on perioperative and 180-day complication rates after total shoulder arthroplasty

BackgroundChronic kidney disease (CKD) is associated with increased risk of complications in total hip arthroplasty and total knee arthroplasty. Despite this known association, there are little data regarding the effect of outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study is to identify the effects of CKD on patient outcomes after TSA.MethodsThe National Readmissions Database was queried from 2010 to 2017 to identify all primary TSA patients (n = 62,455). CKD was identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Chi-squared analysis and multivariate regression were used to analyze differences in outcomes and the impact of CKD stage.ResultsCKD patients had higher rates of 180-day readmissions, 180-day mortality, acute renal failure (ARF), transfusions, urinary tract infections (UTI), acute respiratory distress syndrome (ARDS), pneumonia, and gastrointestinal (GI) complications. Stage 3 CKD (odds ratio [OR] = 1.378; P = .002), stage 4 CKD (OR = 1.805; P = .027), and unspecified CKD stage (OR = 1.787; P < .001) were at increased odds of 180-day readmission. Stage 4 CKD (OR = 10.647; P = .034) was associated with increased odds of 180-day mortality. Stage 2 CKD had increased odds of GI complications (OR = 8.365; P = .004). Both stage 3 CKD (OR = 1.463; P = .038) and stage 4 CKD (OR = 2.465; P = .033) had increased odds of UTI. Stage 5 CKD (OR = 36.143; P < .001) had increased odds of ARDS. Stage 2 CKD had increased odds of thrombosis (OR = 7.869; P = .007). Stage 2 (OR = 4.826; P < .001), stage 3 (OR = 5.724; P < .001), stage 4 (OR = 11.162; P < .001), stage 5 (OR = 31.328; P < .001), and unspecified CKD stage (OR = 4.801; P < .001) were associated with increased odds of ARF. Stage 2 CKD (OR = 12.809; P = .014), stage 3 (OR = 7.351; P = .001), and stage 4 (OR = 39.684; P < .001) were associated with increased odds of transfusions.ConclusionCKD is associated with increased risk of complications, including postoperative ARF, transfusions, UTI, ARDS, pneumonia, and GI complications. Patients with CKD also have increased 180-day readmission rates and 180-day mortality rates. Increasing stage of CKD is associated with increasing odds of 180-day readmission, postoperative ARF, and transfusions. Surgeons should consider these increased risks in the decision-making process during preoperative evaluation. These complications would likely increase cost, which raises the need for further evaluation and stratification of risk in patients who use bundled payment systems.Level of evidenceLevel III; Case-Control Study     

Increased Medical Complications Following Primary Total Hip Arthroplasty in Patients With Solid Organ Transplant: A Matched Cohort Analysis

BackgroundAs patient longevity increases following solid organ transplantation (SOT), more transplant patients are undergoing total hip arthroplasty (THA). The purpose of this study is to compare 90-day postoperative complications and 2-year surgical complications following primary THA in patients with and without a history of SOT.MethodsPatients with a history of SOT with subsequent primary THA between 2010 and 2018 were identified in a national all-payer claims database (PearlDiver Technologies). This SOT cohort was propensity-matched with a control cohort (no history of SOT) based on age, gender, Charlson Comorbidity Index, and obesity with bivariate analysis to compare outcomes between cohorts.ResultsFollowing matching, 3103 patients were included in the SOT cohort and 6196 patients in the control cohort. The cohorts were successfully matched, with no differences in demographics or comorbidities. Relative to the control cohort, patients with a history of SOT were at significantly increased risk of renal failure (P < .001), anemia (P < .001), arrhythmia with and without atrial fibrillation (P < .001), blood transfusion (P < .001), cellulitis (P = .048), myocardial infarction (P < .001), pneumonia (P = .036), heart failure (P < .001), and sepsis (P = .038) at 90 days postoperatively. There were no significant differences between the cohorts in 2-year surgical revisions, regardless of indication.ConclusionFollowing primary THA, patients with a history of SOT are at increased risk of 90-day medical complications but not 2-year surgical complications or revisions relative to patients without SOT. Clinicians should be mindful of the increased risk for cardiopulmonary, renal, hematologic, and infectious complications when counseling and managing this patient population.Level of EvidenceLevel IV-Retrospective Database Study.     

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care “Value”

BackgroundValue is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF).MethodsBetween October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01).ResultsThere were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001).ConclusionAmong Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.     

Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundThere is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA.MethodsWe searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders.ResultsThe risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I² = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I² = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001).ConclusionMental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.     

Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty

BackgroundThe association between malnutrition and complications following primary total joint arthroplasty is well-delineated; however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient’s nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA.MethodsA retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5 = underweight, 18.5-29.9 = healthy/overweight, ≥30 = obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus), and preoperative serum albumin (<3.5 = malnourished, ≥3.5 = non-malnourished). Multivariate analyses were performed using chi-square tests and multiple logistic regressions.ResultsIn all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (P < .001), while those with IDDM had a higher rate of malnutrition (P < .001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (P < .05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (P < .001), urinary tract infection (P < .001), requiring a blood transfusion (P < .001), sepsis (P < .001), and septic shock (P < .001). Malnourished patients also have worse postoperative pulmonary and renal function.ConclusionPatients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.     

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis

BackgroundThere is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population.MethodsA systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4).ResultsA total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively).ConclusionLiver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.