Gender differences of venous thromboembolism risk after total hip and total knee arthroplasty: a meta-analysis

Prevalence and clinical burden of venous thromboembolic events (VTEs) in contemporary total knee arthroplasties (TKAs) in US hospitals

Introduction

Total knee arthroplasty (TKA) is a highly demanded procedure in orthopedic surgery, with over 1.3 million joint arthroplasties performed annually in the U.S. The increasing need for TKAs is driven by an aging population, rising obesity rates, and advances in surgical techniques. Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), significantly impacts TKA patients' mortality and morbidity. Despite advances in prophylaxis and Enhanced Recovery After Surgery (ERAS) protocols reducing VTE incidence, survival rates have not markedly improved. This study aims to identify preoperative predictors of PE and DVT in TKA patients and examine their impact on hospital stays and mortality.

Methods

A retrospective observational study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, focusing on 367,365 TKA patients from 2016 to 2021. Preoperative variables, including demographic factors, comorbidities, and functional status, were analyzed. Primary endpoints were PE and DVT predictors; secondary endpoints included 30-day mortality and prolonged hospital stay. Univariate and logistic regression analyses were performed using SPSS version 26.

Results

Univariate analysis revealed significant associations of male gender, older age, Hispanic ethnicity, smoking, dyspnea, CHF, and COPD with DVT and PE. Multivariate analysis confirmed female sex, younger age, Hispanic ethnicity, and COPD as independent DVT predictors, and independent functional status, smoking, COPD, CHF, and metastatic malignancy as PE predictors. VTE prevalence was 1.09 % (0.67 % DVT, 0.42 % PE), with PE associated with higher mortality (0.78 %) and prolonged hospital stays.

Conclusion

Demographic and clinical variables significantly influence VTE risk post-TKA. Tailored interventions and comprehensive preoperative assessments are crucial for optimizing patient outcomes and reducing thrombotic risks.

Predictors and risk factors of pulmonary embolism after total hip arthroplasty: an NSQIP study

INTRODUCTION

Pulmonary embolism (PE) is a well-known contributor to morbidity after total hip arthroplasty (THA). Considerable efforts have been invested in reducing PE occurrence through pharmacological and perioperative interventions. Nonetheless, the effectiveness of these strategies in reducing the incidence and overall mortality associated with pulmonary embolism events remains a matter of debate. Therefore, identifying risky patients has been gaining importance.

METHODS

We utilised data from the National Surgical Quality Improvement Program (NSQIP) participant usage file (PUF) database spanning the years 2016 to 2021. All preoperative parameters were analysed with chi-square afterwards, meaningful ones were run with logistic regression test.

RESULTS

A study examined factors influencing pulmonary embolism (PE) prevalence in 235,393 total hip arthroplasty patients. Univariate analysis identified significant associations between PE and female gender, diabetes, smoking, dyspnea, CHF, COPD, hypertension (HT), bleeding disorders, disseminated cancer, steroid use, and functional health status. Multivariate analysis revealed male gender as protective, while COPD, hypertension, and disseminated cancer increased PE risk. Notably, smoking appeared protective. PE patients had higher return-to-operation rates (41.7% vs. 2.2%) but similar 30-day mortality (0.2% vs. 0.04%), though mortality's odds ratio was not significant.

CONCLUSIONS

Our findings suggest that certain patient characteristics, such as COPD and metastatic malignancy, significantly influence the likelihood of PE development.

The Validation and Modification of the Caprini Risk Assessment Model for Evaluating Venous Thromboembolism after Joint Arthroplasty

BACKGROUND

 The Caprini risk assessment model (RAM) is the most commonly used tool for evaluating venous thromboembolism (VTE) risk, a high score for arthroplasty can result in patients being classified as high risk for VTE. Therefore, its value in post-arthroplasty has been subject to debate.

METHODS

 Retrospective data were collected from patients who underwent arthroplasty between August 2015 and December 2021. The study cohort included 3,807 patients, all of whom underwent a thorough evaluation using Caprini RAM and vascular Doppler ultrasonography preoperatively.

RESULTS

 A total of 432 individuals (11.35%) developed VTE, while 3,375 did not. Furthermore, 32 (0.84%) presented with symptomatic VTE, while 400 (10.51%) were detected as asymptomatic. Additionally, 368 (9.67%) VTE events occurred during the hospitalization period, and 64 (1.68%) cases were detected during postdischarge follow-up. Statistical analysis revealed significant differences between the VTE and non-VTE groups in terms of ages, blood loss, D-dimer, body mass index >25, visible varicose veins, swollen legs, smoking, history of blood clots, broken hip, percent of female, hypertension, and knee joint arthroplasty (p < 0.05). The Caprini score was found to be significantly higher in the VTE group (10.10 ± 2.23) compared with the non-VTE group (9.35 ± 2.14) (p < 0.001). Furthermore, there was a significant correlation between the incidence of VTE and the Caprini score (r = 0.775, p = 0.003). Patients with a score ≥9 are at a high-risk threshold for postoperative VTE.

CONCLUSION

 The Caprini RAM shows a significant correlation with the occurrence of VTE. A higher score indicates a greater likelihood of developing VTE. The score ≥9 is at particularly high risk of developing VTE.

An analysis of the prevalence and risk factors of deep vein thrombosis in non-fracture patients awaiting total hip arthroplasty: a retrospective study of 1244 cases

BACKGROUND

Deep vein thrombosis (DVT) has been one of the most dangerous complications in total hip arthroplasty (THA). If a patient's pre-surgical DVT is overlooked, it can easily be mistaken for a post-operative thrombus and lead to an increased risk of DVT during and after surgery. This retrospective study was to explore the incidence and associated risk factors of deep vein thrombosis (DVT) in non-fracture patients before total hip arthroplasty (THA).

METHODS

From September 2015 to September 2020, 1242 patients admitted for THA were enrolled with 1120 patients (90.2%) for primary THA and 122 patients (9.8%) for revision THA. An experienced sonographer performed a bedside ultrasound to detect DVT in bilateral lower limbs preoperatively. Univariate and logistic regression analysis was performed to identify the independent risk factors.

RESULTS

38 patients (3.1%) were detected with preoperative DVT. Univariate analysis showed that age (P < 0.001), D-dimer level (P = 0.002), female patients (P = 0.016), revision THA (P < 0.001), Barthel Index score (P = 0.010) were significantly associated with preoperative DVT. In subgroup comparison, the incidence of DVT increased with age significantly (P < 0.001) and D-dimer level (P < 0.001). In logistic regression analysis, age ≥ 75 years old (odds ratio [OR] 3.678, 95% CI [2.197-18.721], P < 0.001), gender (OR 2.709, 95% CI [1.244-5.896], P = 0.012), higher D-dimer ≥ 0.5 mg/l (OR 6.841, 95% CI [2.197-18.721], P < 0.001) and revision THA (OR 2.240, 95% CI [1.143-5.372], P = 0.05) were confirmed as the independent risk factors.

CONCLUSIONS

The incidence of preoperative DVT in non-fracture patients was 3.1%, with 2.4% in primary THA and 9.0% in revision THA. Age ≥ 75 years old, female, D-dimer ≥ 0.5 mg/l, and revision THA were independent risk factors. When evaluating the risk factors associated with thrombus formation preoperatively, it is important to take these into account before surgery.

Associations of parecoxib and other variables with recovery and safety outcomes in total knee arthroplasty: insights from a retrospective cohort study

Background

Early mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.

Methods

This study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007-2012 and 2013-2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.

Results

Parecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = -0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007-2018, but gender had no significant association with LOS during the period of 2013-2018. The 2013-2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1-2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.

Conclusion

In this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

Women Are Underrepresented Among Principal Investigators of Hip and Knee Arthroplasty Clinical Trials in the United States

BACKGROUND

Leadership of clinical trials confers national recognition and promotes academic advancement. We hypothesized that women would be underrepresented among principal investigators (PIs) of hip and knee arthroplasty clinical trials in the United States.

METHODS

A query of hip and knee arthroplasty clinical trials from 2015 to 2021 was performed on ClinicalTrials.gov. Clinical trials were included if they involved a U.S.-based orthopaedic-surgeon PI. We analyzed the sex representation of arthroplasty PIs among junior-level (assistant professor) and senior-level (associate or full professor) faculty. Participation-to-prevalence ratios (PPRs) were calculated by comparing the sex representation among arthroplasty PIs with that among academic arthroplasty faculty at institutions conducting hip and knee arthroplasty clinical trials. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation.

RESULTS

A total of 157 clinical trials involving 192 arthroplasty PIs were included. Of these PIs, only 2 (1.0%) were women. PIs were mostly funded by academic institutions (66%) and industry (33%). U.S. federal sources funded a minority (1%) of PIs. Of the 243 male arthroplasty faculty who were eligible, 190 men (78.2%) served as PIs. In contrast, of the 17 female arthroplasty faculty who were eligible, only 2 women (11.8%) served as PIs (p < 0.001). Across the entire cohort of arthroplasty PIs, women were underrepresented (PPR = 0.16), whereas men were equitably represented (PPR = 1.06). Women were underrepresented at the assistant professor (PPR = 0.0), associate professor (PPR = 0.52), and full professor (PPR = 0.58) levels.

CONCLUSIONS

Women were underrepresented among PIs of hip and knee arthroplasty clinical trials, which may lead to disparities in academic promotion and advancement. More research is needed to understand the potential barriers to female leadership of clinical trials. Greater awareness and engagement are needed to create sex equity in clinical trial leadership for hip and knee arthroplasty research.

CLINICAL RELEVANCE

The underrepresentation of women among arthroplasty PIs may lead to fewer options in surgical providers for patients and may limit access to musculoskeletal care for certain patient populations. A diverse arthroplasty workforce can promote attention to issues that disproportionately affect historically underrepresented and vulnerable patient populations.

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

Sex-Based Differences in the Presentation and Outcomes of Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

BACKGROUND

The study aimed to review differences in the presentation and outcomes of acute pulmonary embolism (PE) between men and women.

METHODS

PubMed, CENTRAL, Web of Science, and Embase were searched for studies comparing clinical features or outcomes of PE between men and women. Baseline comorbidities, risk factors, clinical features, and mortality rates were also compared between men and women.

RESULTS

Fourteen studies were included. It was noted that men presented with PE at a statistically significantly younger age than women (P < .001). Smoking history (P < .001), lung disease (P = .004), malignancy (P = .02), and unprovoked PE (P = .004) were significantly more frequent among men than among women. There was no difference between the sexes for hypertension, diabetes, and a history of recent immobilization. A significantly higher proportion of men presented with chest pain (P = .02) and hemoptysis (P < .001), whereas syncope (P = .005) was more frequent in women. Compared with men, women had a higher proportion of high-risk PE (P = .003). There was no difference in the use of thrombolytic therapy or inferior vena cava filter. Neither crude nor adjusted mortality rates were significantly different between men and women.

CONCLUSION

This review found that the age at presentation, comorbidities, and symptoms of PE differed between men and women. Limited data also suggest that women more frequently had high-risk PE compared with men, but the use of thrombolytic therapy did not differ between the 2 sexes. Importantly, both crude and adjusted data show that the mortality rate did not differ between men and women.

Association between glycosylated hemoglobin, diabetes mellitus, and preoperative deep vein thrombosis in patients undergoing total joint arthroplasty: a retrospective study

Background

To investigate the association between the level of glycosylated hemoglobin (HbA1c) and preoperative deep vein thrombosis (DVT) and that between diabetes mellitus (DM) and preoperative DVT in patient undergoing total joint arthroplasty (TJA).

Methods

A total of 1386 patients were enrolled. We created the receiver operating characteristic (ROC) curve of HbA1c, and based on the cutoff value, patients were divided into two groups. Risk factors were subsequently examined. Chi-square test or Fisher’s exact test was adopted for enumeration data. The results were expressed in percentages (%), and DVT-related variates were analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis and calculated the adjusted odds ratio (OR) and 95% confidence interval (95% CI).

Results

Preoperative DVT was 100 cases (7.22%) and DM in 301 cases (21.7%). We determined the cutoff value of HbA1c of 6.15% using the ROC curve as the area under the curve (AUC) was 0.548. Univariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM, female, and major surgery in the last 12 months increased by 1.84 (P = 0.005; 95% CI [1.20–2.80]), 2.22 (P = 0.028, 95% CI [1.09–4.52]), 2.47 (P = 0.013, 95% CI [1.21–5.04]), 2.03 (P = 0.004, 95% CI [1.25–3.30]); 1.85 (P = 0.010, 95% CI [1.16–2.95]); and 2.86 times (P = 0.006, 95% CI [1.35–6.05]), respectively. And multivariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM patients, female patients, and major surgery in the last 12 months increased by 1.77 (P = 0.009, 95% CI [1.16–2.72]); 2.10 (P = 0.043, 95% CI [1.02–4.30]); 2.50 (P = 0.013, 95% CI [1.22–5.14]); 2.01 (P = 0.005, 95% CI [1.23–3.28]); 1.80 (P = 0.014, 95% CI [1.13–2.89]); and 3.04 times (P = 0.004, 95% CI [1.42–6.49]), respectively.

Conclusion

We conclude that HbA1c ≥ 6.15%, DM, female and major surgery in the last 12 months are the independent risk factors for preoperative DVT in patients undergoing TJA. And patients with a higher HbA1c level are at an increased risk of preoperative DVT.

Trial registration: ChiCRT2100054844.

What Are the Drivers of Readmission for Serious Venous Thromboembolic Events after Primary Total Knee Arthroplasty? An Analysis of 862,915 Patients

Venous thromboembolism (VTE) is a relatively common complication among patients undergoing primary total knee arthroplasty (TKA). This complication occurs in a spectrum of severity ranging from an incidental finding to serious readmission-requiring events. To date, the risk factors of serious VTE that require readmission have not been characterized. This study examines the patient and hospital characteristics associated with readmission for serious VTE after TKA. The National Readmission Database (NRD) from the Agency of Healthcare Research and Quality (AHRQ) was queried for patients who underwent primary TKA from January 2016-December 2018. The study population consisted of patients who were readmitted within 90 days following primary TKA with a primary diagnosis of VTE. Multivariable regression models were constructed to evaluate patient characteristics (age, sex, insurance, elective nature of procedure, hospital characteristics, discharge status, income, and comorbidities) associated with higher risk of developing readmission-requiring VTE. Readmission rates for VTE exhibited a higher incidence in patients older than 61 (compared with 40 and under), males (OR:1.08, 95%CI [1.03-1.14]), patients with nonelective procedures (OR:20.21, 95% CI [19.16-21.32]), patients at large hospitals(OR:1.17, 95% CI [1.09-1.25]), patients at private hospitals (OR:1.19, 95% CI [1.09-1.29]), and patients with non-home discharge statuses. Comorbidities of paralysis (OR:1.52, 95% CI [1.19-1.94]), neurological disorders (OR:1.12, 95% CI [1.02-1.23]), metastatic cancer (OR:1.48, 95% CI [1.01-2.17]), obesity (OR:1.11, 95% CI [1.06-1.17]), fluid and electrolyte imbalance (OR:1.28, 95% CI [1.18-1.38]), blood loss anemia (OR:1.29, 95% CI [1.02-1.64]), and iron deficiency anemia (OR:1.24, 95 % CI [1.15-1.33]) increased risk of VTE. Certain comorbidities requiring chronic anticoagulation were associated with lower risk of VTE. Insurance status and patient income did not exhibit any correlation with VTE incidence. Patient characteristics of male sex, age > 61, and baseline comorbidities (paralysis, neurological disorders, metastatic cancer, obesity, fluid and electrolyte imbalance, and blood loss/iron deficiency anemia) were at an increased risk of developing serious VTE. Patients without continued supervision at their discharge environment were at higher risk of developing serious VTE. Extra prophylaxis and special protocols may be warranted in these patients to prevent VTE complications.

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

BACKGROUND

Venous 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.

METHODS

The 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.

RESULTS

Higher 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).

CONCLUSION

One 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.

Gender Differences do not Influence the Blood Coagulopathy in Patients Undergoing Total Knee Arthroplasty: A Retrospective Thromboelastography Analysis

Objective

Deep vein thrombosis (DVT) is one of the severe complications after total knee arthroplasty (TKA). Gender has been considered to influence the incidence of the thrombosis formation in TKA patients. However, it remains controversial which gender would be more prone to form thrombosis. The aim of this study was to assess the effects of gender differences on coagulation status after TKA via the thromboelastography (TEG).

Methods

A total of 57 male patients who underwent primary TKA from September 2015 to January 2021 were included in this study. According to the matching principle of age, body mass index (BMI), and anticoagulation treatment, 60 female patients were selected. The conventional coagulation tests, routine blood tests, and thromboelastography were conducted before the operation, 1 day and 7 days after the operation. In addition, Doppler ultrasound was also performed 1 day before the operation and at the 7 days after the operation. The parameters of conventional coagulation tests, routine blood tests, and thromboelastography were compared between the two groups.

Results

There were no significant differences in the blood transfusion rate, the incidence of DVT during the perioperative period, D-dimer (D-D), fibrin degradation products (FDP), hemoglobin (HB), hematocrit (HCT), prothrombin time (PT), activated partial thromboplastin time (APTT), and C-reactive protein (CRP) at any corresponding time point between the male group and the female group (P > .05). There were no significant differences in neutrophil-to-lymphocyte ratio (NLR) preoperatively; however, there were significant differences in NLR 1 day after the surgery and 7 days after the surgery between the two groups (P < .05). There were significant differences in reaction time (R) and α angle 1 day after the surgery between the two groups (P < .05), but there were no significant differences in other TEG indexes at any corresponding time point between the two groups (P > .05). Binary logistic regression analysis demonstrated that gender, age, BMI, tourniquet application time were not independent predictors (P > .05).

Conclusion

Gender differences have no significant influence in TKA patients with regard to conventional coagulation tests and thromboelastography.

Effect of Gender Differences on Patient-Reported Outcomes and Complications in Total Ankle Replacement

BACKGROUND

The purpose of this study was to evaluate gender differences in patient outcomes and complications following total ankle replacement (TAR).

METHODS

Consecutive patients who underwent primary TAR from July 2007 through May 2016 were prospectively followed and retrospectively reviewed. Demographic, operative, patient-reported outcomes (PROs), and complication data were collected and analyzed. PROs included the visual analog scale (VAS), 36-Item Short-Form Health Survey (SF-36), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Short Musculoskeletal Function Assessment (SMFA). A total of 475 patients were evaluated, including 248 males (52.2%) and 227 females (47.8%) with an average of 56.8 months follow-up.

RESULTS

Women were more likely to have inflammatory arthritis (13.7% vs 2.8%; P < .01) and significantly worse preoperative SF-36 total, SF-36 mental health component, AOFAS total, AOFAS pain, SMFA function, and SMFA bother scores (all P < .05). Both genders demonstrated significant improvement in PROs at 1, 2, and 5 years. The magnitude of improvement was similar between genders for all PROs (all P < .05) with the exception of SF-36 physical function, which was greater in men. Females underwent more nonrevision reoperations (32.2% vs 22.6%; P = .0191), but there was no significant difference in failure rates (male 7.3% vs female 3.5%; P = .07). The reoperation and failure rates at 2 years postoperation were 10.1% and 1.6% for men and 18.5% and 0.9% for women, respectively.

CONCLUSION

Women undergoing TAR were more likely to have worse preoperative PROs and higher rates of nonrevision reoperations, which remains true when controlling for their increased incidence of inflammatory arthritis. However, women reported similar improvements in PROs and had similar prosthetic survival rates as men. Increased understanding of these disparities, combined with gender-based interventions, may further advance patient outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic, retrospective comparative series.

Factors associated with the length of stay in total knee arthroplasty patients with the enhanced recovery after surgery model

Objectives

The purpose of this study is to identify the factors that influence the length of stay (LOS) in total knee arthroplasty (TKA) patients with an enhanced recovery after surgery (ERAS) program.

Methods

Information from 167 patients (31 males and 136 females, range from 43 years to 88 years old) who underwent the unilateral elective primary TKA from January 2017 to January 2019 were reviewed retrospectively. Factors were analyzed by single-factor variance and multi-factor linear regression.

Results

By single-factor variance analysis, American Society of Anesthesiologists (ASA) physical status classification system, pre-operation albumin, pre-operation erythrocyte sedimentation rate (ESR), primary and merge diseases, hidden blood loss, and length of operation were correlated with LOS (P < 0.05). Multi-factor linear regression results suggested that gender, ASA class, pre-operation Alb, and pre-operation ESR were associated with LOS (P < 0.05). Moreover, ASA class 3 (B value 4.84), pre-operation Alb < 30 g/L (B value 18.33), and pre-operation ESR > 15 mmol/h (B value 2.21) could increase the LOS, while males (B value − 3.56) had a shortened LOS.

Conclusions

Overall, our research found that female, ASA class 3, pre-operation Alb < 30 g/L, and pre-operation ESR > 15 mmol/h could extend LOS in TKA patients with ERAS.

Gender Differences for Hip and Knee Arthroplasty: Complications and Healthcare Utilization

INTRODUCTION

The influence of patient gender on complications and healthcare utilization remains unexplored. The purpose of the present study was to determine if patient gender significantly affected outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Retrospective cohort study of THA and TKA patients was performed using the Nationwide Inpatient Sample from 2002 to 2011. Only patients who underwent elective procedures and those with complete perioperative data were included. Multivariate logistic regression was used to compare the rates of adverse events between male and female cohorts while controlling for baseline characteristics.

RESULTS

A total of 6,123,637 patients were included in the study (31.2% THA and 68.8% TKA). The cohort was 61.1% female. While males had a lower rate of any adverse event (odds ratio [OR] = 0.8, P < .001), urinary tract infection (OR = 0.4, P < .001), deep vein thrombosis/pulmonary embolism (OR = 0.9, P < .001), and blood transfusion (OR = 0.5, P < .001), male gender was associated with statistically significant increases in the rates of death (OR = 1.6, P < .001), acute kidney injury (OR = 1.6, P < .001), cardiac arrest (OR = 1.7, P < .001), myocardial infarction (OR = 1.6, P < .001), pneumonia (OR = 1.1, P < .001), sepsis (OR = 1.6, P < .001), surgical site infection (OR = 1.4, P < .001), and wound dehiscence (OR = 1.4, P < .001).

CONCLUSION

Males had increased rates of many individual adverse events. Females had higher rates of urinary tract infection, which translated to an overall higher rate of adverse events in females because of the rarity of the other individual adverse events.

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty

BACKGROUND

There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA.

METHODS

Electronic searches were completed using Ovid, PubMed, and Embase databases. Studies were included if (1) they are published in the English language between 2000 and 2016; (2) they included patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (3) they evaluated prevention and control of postoperative VTE with at least one of the following thromboprophylactic agents: aspirin, enoxaparin, dalteparin, dabigatran, apixaban, rivaroxaban, dabigatran, ximelagatran, fondaparinux, or coumadin. Data were extracted and analyzed via mixed-effect logistic regression.

RESULTS

Fifty-seven studies were included; 29 were industry funded, and 28, nonfunded. There were no significant differences between patient's age, body mass index, or revision exclusions between funded and nonfunded studies. Funded studies reported less pulmonary embolisms, fewer events of major bleeding, and significantly less 90-day mortality compared with nonfunded studies.

CONCLUSION

Industry-funded studies reported less pulmonary embolisms, major bleeding, and mortality compared with nonfunded studies. Detailed demographic data were missing from the literature, and we were unable to demonstrate the cause of different reported outcomes between industry-funded and nonfunded studies. Further investigations should be aimed toward understanding how funded studies report less adverse outcomes in analyzing VTE after TJA.

Venous Thromboembolism in Podiatric Foot and Ankle Surgery

BACKGROUND

The extent to which podiatric surgeons follow venous thromboembolism guidelines is unknown. The aim of this study therefore, was 2-fold: (a) to determine the rate of venous thromboembolism following podiatric surgery and (b) to investigate the factors that influence the use of thromboprophylaxis.

METHODS

Data from 4238 patients who underwent foot and ankle surgery over 2 years were analyzed. Venous thromboembolism within the first 30 days following surgery was recorded using the Australasian College of Podiatric Surgeons surgical audit tool. Logistic regression analyses were undertaken to determine the factors that influenced thromboprophylaxis.

RESULTS

Of the 4238 patient records, 3677 records (87%) provided complete data (age range 2-94 years; mean ± SD, 49.1 ± 19.7 years; 2693 females). A total of 7 venous thromboembolic events (0.2% rate) were reported. Operative duration and age (OR 12.63, 95% CI 9.47 to 16.84, P < 0.01), postoperative immobilization (OR 6.94, 95% CI 3.95 to 12.20, P < 0.01), and a prior history of VTE (OR 3.41, 95% CI 1.01 to 11.04, P = 0.04) were the strongest predictors of thromboprophylaxis.

CONCLUSION

Podiatric foot and ankle surgery is associated with a low rate of venous thromboembolism. This may be due in part to the thromboprophylaxis regime implemented by podiatric surgeons, which closely aligns with current evidence-based guidelines.

LEVELS OF EVIDENCE

Level II: Prospective cohort study.

Are Medicare's "Comprehensive Care for Joint Replacement" Bundled Payments Stratifying Risk Adequately?

BACKGROUND

Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program.

METHODS

Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period.

RESULTS

Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R² = 0.23 vs 0.17).

CONCLUSION

More robust risk stratification could provide more equitable reimbursement in the CJR program.

LEVEL OF EVIDENCE

Large database analysis; Level III.

Influence of type 2 diabetes mellitus on Khorana venous thromboembolism risk in colorectal cancer patients

BACKGROUND

Many studies have documented the association between venous thromboembolism (VTE) and colorectal cancer (CRC). The Khorana model is a VTE risk assessment model for predicting cancer-associated thrombosis. Type 2 diabetes (T2DM) has also been reported to increase the risk of VTE.

PURPOSE

The aim of this study was to investigate the influence of T2DM on Khorana VTE risk in CRC patients and to explore the relationship between Khorana VTE category and CRC clinicopathological factors.

METHODS

This analysis included 615 CRC patients (205 with T2DM). Fibrinogen and D-dimer levels were compared within each group. A comparison was made of the proportion of patients in different Khorana VTE risk categories in CRC patients with and without T2DM. The association between Khorana VTE risk category and clinicopathological factors among all the CRC patients was evaluated.

RESULTS

Fibrinogen levels of CRC patients with T2DM were significantly higher than those of non-diabetes patients (4.13 ± 1.06 vs 3.94 ± 0.98, p < 0.001). A higher proportion of CRC patients with T2DM were in the Khorana intermediate-to-high risk category (H = 4.749, p = 0.029). Female sex, diabetes, colon location (compared with rectum), larger tumor size, advanced pT stage and pN stage were correlated with the intermediate-to-high Khorana VTE risk category, with odd ratios (95% confidence intervals [CI]) of 1.537 (1.064-2.220), 1.499 (1.027-2.186), 2.313 (1.588-3.370), 2.284 (1.542-3.383), 4.429 (2.088-9.396) and 1.822 (1.230-2.698), respectively.

CONCLUSION

T2DM increases Khorana VTE risk in CRC patients. Female sex, diabetes, colon location, large tumor size and poor stage are associated with the intermediate-to-high Khorana VTE risk category.