Higher revision and complication rates following total hip arthroplasty in patients with inflammatory bowel disease

Ulcerative Colitis Patients Are at Increased Risk for Adverse Events Following Total Hip Arthroplasty

BACKGROUND

Patients who have the autoinflammatory bowel disease ulcerative colitis (UC) may become candidates for total hip arthroplasty (THA). Having UC may predispose patients to postoperative adverse events, but it remains unclear if these events are related more to the disease process itself or perhaps related to the medications used to treat the condition.

METHODS

Patients undergoing THA were identified from a large administrative dataset. Those who did not have and those who had UC were matched 4:1 based on patient age, sex, and the Elixhauser Comorbidity Index. Matched THA patients who did not have UC (n = 19,482) and those who had UC (n = 4,874) were identified. The matched groups were compared regarding 90-day adverse and five-year survival. Further analyses were performed based on classes of medications.

RESULTS

Controlling for patient age, sex, and Elixhauser Comorbidity Index, UC patients were at significantly higher odds of 90-day adverse events: any (odds ratio [OR]: 1.59), severe (OR: 1.72), and minor (OR: 1.63) (all P < 0.001). Despite this, no differences in 5-year survival were identified. Relative to those who did not have UC, there were increasing odds of any adverse event based on the potency of related medications: no corticosteroids/immunomodulators/5-aminosalicylic acid (5-ASA) (OR: 1.42), corticosteroids only (OR: 1.58), 5-ASA ± corticosteroids OR (1.72), and immunomodulators ± corticosteroids (OR: 1.74, all P < 0.001).

CONCLUSIONS

Total hip arthroplasty patients who have UC were at higher odds for 90-day postoperative adverse events relative to those who did not have UC, and this risk was even greater for those on defined classes of medications. Total hip arthroplasty patients who have UC bear specific considerations, and surgeons must carefully consider and manage the patient's medication regimen in the perioperative period of the THA.

Inflammatory Bowel Disease as a Risk Factor for Complications and Revisions Following Lumbar Discectomy

Study DesignRetrospective cohort study.ObjectivesPatients with IBD are at an increased risk for postoperative complications following surgery. The goal of this study is to investigate if inflammatory bowel disease (IBD) is a risk factor for complications following lumbar discectomy.MethodsWe identified IBD patients who underwent lumbar discectomy for lumbar disc herniation (LDH) and matched to them with controls without IBD in a1:5 ratio. We excluded patients with a history of spinal injury, cancer, infection, trauma, or surgery to remove the digestive tract. We used multivariate logistic regression analyses to compare postoperative outcomes, including 90-day complications, 90-day emergency department visits, and 90-day readmissions. In addition, 2-year re-discectomy rates and a 3-year lumbar fusion rate were compared between the cohorts.ResultsAfter applying the study criteria, we identified 6134 IBD patients with LDH for further analysis. With the exception of dura tears, patients with IBD had significantly higher rates of medical complications, incision-related complications, ED visits, and readmission rates compared to patients without IBD, especially for the 2-year and 3-year rates of disc recurrence and revision surgery.ConclusionsPatients with IBD who underwent lumbar discectomy are at a significantly higher rate of complications. Therefore, spine surgeons and other health care providers should be aware of this higher risk associated with IBD patients and properly treat the patients' IBD before surgery to lower these risks.

Inflammatory Bowel Disease and Joint Surgery: A 20-Year Cohort Study of Arthroplasty and Arthritis Risks

Background Patients with inflammatory bowel disease (IBD) have a higher risk of adverse outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) compared to the general population. However, existing literature has not fully elucidated the risk of IBD patients to undergo arthroplasty for treatment of arthritis. Therefore, the purpose of this study is to understand the incidence of arthroplasty and osteoarthritis, enteropathic arthritis, or inflammatory polyarthropathies in patients with IBD compared to the general population. Methods A retrospective cohort analysis was conducted using the TriNetX research database to identify all patients who experienced the primary outcomes between 2004 and 2024. Two cohorts were stratified by a diagnosis of IBD and propensity score matched (1:1) to mitigate baseline differences in demographics and comorbidities. Results After propensity matching, each cohort contained 531,263 patients who were included for analysis. Patients with IBD were significantly less likely to undergo THA (OR 0.853, 95% CI 0.804-0.906) and TKA (OR 0.830, 95% CI 0.788-0.874) and less likely to incur a diagnosis of hip osteoarthritis (OR 0.943, 95% CI 0.922-0.965) or knee osteoarthritis (OR 0.794, 95% CI 0.780-0.808). Conversely, IBD patients were significantly more likely to incur a diagnosis of enteropathic arthropathy (OR 287.9, 95% CI 181.3-457.5) or inflammatory polyarthropathies (OR 1.390, 95% CI 1.365-1.414). Conclusions Patients with IBD are less likely to undergo THA and TKA despite the association between IBD and arthritis. These findings underscore the importance of tailored treatment strategies for joint-related complications in IBD patients and highlight the need for further research to optimize surgical outcomes in this population.

Equivalent Survivorship of Total Hip Arthroplasty in Patients Who Have Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) can have orthopaedic manifestations related to decreased bone mineral density and increased fracture risk. The impact of IBD-spectrum diseases, including Crohn's disease (CD) and ulcerative colitis (UC), on the overall performance of total hip arthroplasty (THA), is not well understood. The present study sought to evaluate whether patients who have IBD were at an increased risk of THA failure compared to those who did not have IBD.

METHODS

The Statewide Planning and Research Cooperative System was used to compare postoperative outcomes between patients who have IBD (CD and UC) and patients who do not have IBD from 2010 to 2020. A total of 119,094 patients were included in the study, of whom 1,165 had a diagnosis of IBD. Overall, 501 of those had CD, while 664 had UC.

RESULTS

When controlling for comorbidities, patients who had CD had longer hospital length of stay (CD: 3.6 ± 2.5 versus UC: 3.4 ± 2.1 versus control: 3.2 ± 2.3 days, P < 0.001), higher rates of 90-day readmission (CD: 13.6 versus UC: 8.3 versus control: 7.7%, P < 0.001) and 1-year readmission (CD: 20.4 versus UC: 15.1 versus control: 12.8%, P < 0.001), and higher rates of 90-day emergency room visits (CD: 15.4 versus UC: 12 versus control: 11.1%, P = 0.007). There were no differences in all-cause revision or revision for periprosthetic joint infection between CD and UC compared with control patients.

CONCLUSIONS

Patients who have UC had more emergency room visits and hospital readmissions following THA; however, survival analysis demonstrated that IBD patients are not at an increased risk of revision or periprosthetic joint infection after THA.

Risk Factors and Outcomes Associated with Emergency Abdominal Surgery following Lower Extremity Total Joint Arthroplasty

Objectives

This study aims to identify potential risk factors and assess postoperative outcomes associated with requiring emergency abdominal surgery (EAS) within 30 days following total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that patients requiring EAS would carry a higher morbidity and mortality rates compared to patients that underwent the index operation alone.

Methods

We conducted a retrospective analysis using TriNetX, examining data from 2016-2024 from patients over 18 years old who underwent THA/TKA and required EAS within 30 days. Postoperative outcomes, including mortality and hospital readmission, were compared between patients requiring EAS and those who did not. Statistical analyses included measures of association and chi-squared tests. Patient demographic data, including age, sex, and comorbidities were analyzed.

Results

Patients requiring EAS within 30 days of a joint arthroplasty were significantly more likely to be older, overweight or obese, and to be diagnosed with comorbidities including diverticular disease, cholelithiasis, alcohol use disorders, and tobacco use. These patients had significantly higher mortality rates within 60 days of joint arthroplasty compared to patients without EAS, suggesting that the second operation contributed significantly to the increase in adverse outcomes.

Conclusion

This study emphasizes the importance of recognizing key risk factors for severe GI complications that require EAS. These findings highlight the need for careful patient selection, pre-operative evaluation of risk, and vigilant post-operative management, especially in those with many risk factors. Improved identification and management of high-risk patients may help reduce the likelihood of EAS and its associated mortality.

Inflammatory bowel disease is associated with greater odds of complications following posterior lumbar fusion and further amplified for patients exposed to monoclonal antibody biologics

Background

Posterior lumbar fusion (PLF) is a common spine surgery that may be considered in patients with underlying comorbidities, such as inflammatory bowel disease (IBD). Prior literature examining the association of this disease and PLF outcomes was done in the National Inpatient Sample (NIS), which only assessed in-hospital data and did not reveal an elevated risk of medical or surgical complications. However, characterization of PLF outcomes beyond hospital discharge is important and remains unknown for patients with IBD.

Methods

Patients with IBD who underwent single-level PLF ± interbody fusion were identified from the M165Ortho PearlDiver database. Exclusion criteria included: patients <18 years old, those undergoing concurrent cervical, thoracic, anterior, or multi-level fusion, those with prior trauma, neoplasm, or infection diagnosed within 90-days, and <90-days of follow-up. Adult patients with IBD were matched 1:4 with non-IBD patients based on age, sex, and Elixhauser Comorbidity Index (ECI). The odds of 90-day individual and aggregated any, severe, and minor adverse events (AAE, SAE, and MAE, respectively), emergency department (ED) visits, and hospital readmission were compared by multivariable logistic regression. Five-year reoperation was assessed by Kaplan-Meier survival analysis and compared by log-rank test.

Results

Overall, 4,392 (1.4%) of patients undergoing PLF were identified with IBD. These patients demonstrated elevated odds ratios (ORs) of aggregated MAE (OR 2.29), AAE (OR 2.27), and SAE (OR 1.84), as well as ED visits (OR 2.69) (p<.001 for all). Conversely, 5-year reoperation rates were not different for those with vs without IBD (p=.70).

Conclusions

The current study highlights the importance of investigating post-discharge outcomes, as these findings were not detected by prior inpatient literature. Our findings reveal the odds of various complications may be significantly elevated for IBD patients within 90-days postoperatively, however, these inferior outcomes encouragingly did not translate to an elevated rate of 5-year reoperation.

Clinical outcomes of total joint arthroplasty in patients with bowel ostomies

INTRODUCTION

The influence of prior colostomy or ileostomy on patients undergoing joint arthroplasty remains poorly understood. Our study aimed to assess whether patients with an ostomy undergoing hip and knee arthroplasties have worse postoperative outcomes and increased rates of revisions.

METHOD

A single-center, retrospective review of patients with a history of bowel ostomy who underwent a primary total hip arthroplasty (THA), hemiarthroplasty (HA), and total knee arthroplasty (TKA) from 2012 to 2021. A total of 24 THAs, 11 HAs, and 25 TKAs in patients with open small or large bowel stoma were identified. A ten-to-one propensity score match was utilized to establish cohorts with comparable demographics but no prior ostomy procedure.

RESULTS

Patients with stomas undergoing elective THA showed greater 90-day ED visits (20.0 vs. 5.0%, P = 0.009), 90-day all-cause readmissions (20.0 vs. 5.0%, P = 0.009), 90-day non-orthopedic readmissions (10.0 vs. 0.5%, P < 0.001), 90-day readmissions for infection (5.0 vs. 0.5%, P = 0.043), all-cause revisions (15.0 vs. 0.5%, P < 0.001), revisions for PJI (5.0 vs. 0%, P = 0.043), and revisions for peri-prosthetic fracture (10.0 vs. 0%, P < 0.001). Patients with stomas undergoing non-elective hip arthroplasties exhibited a longer mean LOS (12.1 vs. 7.0 days, P < 0.001) and increased 90-day all-cause readmissions (40.0 vs. 17.3%, P = 0.034), 90-day orthopedic readmissions (26.7 vs. 6.0%, P = 0.005), all-cause revisions (13.3 vs. 2.0%, P = 0.015), revisions for peri-prosthetic fracture (6.7 vs. 0%, P = 0.002), and revisions for aseptic loosening (6.7 vs. 0%, P = 0.002). There were no significant differences in readmission or revision rates between ostomy patients undergoing TKA and a matched control group.

CONCLUSION

Patients undergoing hip arthroplasties with an open stoma are at an increased risk of hospital encounters and revisions, whereas TKA patients with stomas are not at increased risk of complications. These findings emphasize the importance of recognizing and addressing the unique challenges associated with this patient population.

Inflammatory bowel disease patients undergoing total hip arthroplasty have higher odds of implant-related complications

PURPOSE

This study evaluates whether IBD patients are at increased risk of implant-related complications after THA.

MATERIALS AND METHODS

A retrospective study from 01 January 2010 to 31 October 31 2020 using an administrative claims database was performed. IBD patients undergoing THA (n = 11,025), without corticosteroid treatment, were propensity score matched to controls in a 1:5 ratio (n = 55,121) based on age, sex, and the Charlson Comorbidity Index (CCI). Outcomes evaluated included periprosthetic fracture, aseptic loosening, prosthetic joint infection, and THA revision within 2 years of index procedure. Chi-square analyses were used to compare the matched cohorts. The association of IBD and implant-related complications was evaluated using logistical regression to calculate odds ratios (ORs), 95% confidence intervals (95% CIs), and p-values. A p-value < 0.001 was used as the significance threshold.

RESULTS

Patients with IBD had a greater incidence and odds of total implant complications (7.03% vs. 3.98%; OR 1.76; p < 0.001) compared with matched controls. IBD patients had significantly higher incidence and odds of developing periprosthetic fracture (0.50% vs. 0.20%; OR 2.46; p < 0.001), THA revisions (2.21% vs. 1.17%; OR 1.91; p < 0.001), aseptic loosening (1.45% vs. 0.84%; OR 1.75; p < 0.001), and prosthetic joint infection (2.87% vs. 1.77%; OR 1.64; p < 0.001).

CONCLUSIONS

Patients with IBD who underwent primary THA had a significantly higher risk of implant-related complications compared to matched controls. Providers should use this study to appropriately assess post-complication risk factors for their patients with IBD.

The association of inflammatory bowel disease with postoperative complications, re-admissions and emergency department visits following primary total hip arthroplasty

BACKGROUND

Inflammatory bowel disease (IBD) is a systemic inflammatory disorder of the gut. Few studies have evaluated whether patients with a history of IBD have worse outcomes following primary total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate whether IBD is associated with increased: (1) medical complications; (2) readmissions; and (3) emergency department (ED) visits.

METHODS

Using a nationwide claims database, patients with IBD undergoing primary THA were identified and matched to a comparison group according to age, sex and the Charlson Comorbidity Index. Outcomes assessed included the development of 90-day medical complications, 90-day re-admissions and 90-day ED visit rates. A p-value <0.0001 was considered statistically significant.

RESULTS

Patients with IBD had a greater incidence and odds ratio of total medical complications (31.90% vs. 11.47%; OR 2.89; p < 0.0001) compared with matched controls. IBD patients had significantly higher incidence and odds ratio of developing acute kidney injury (5.46 vs. 1.46%; OR 3.92; p < 0.0001), cerebrovascular accident (1.32 vs. 0.35%; OR 3.79; p < 0.0001), pneumonia (4.02 vs. 1.30%; OR 3.19; p < 0.0001), respiratory failure (1.21 vs. 0.41%; OR 2.94; p < 0.0001), deep vein thrombosis (0.89% vs. 0.30%; OR 2.93; p < 0.0001), and other adverse events. IBD patients also had higher incidence and odds ratio of 90-day re-admissions (4.20% vs. 3.23%; OR 1.31; p < 0.0001) and ED visits (6.56% vs. 3.99%; OR 1.69; p < 0.0001).

CONCLUSIONS

This study found that patients with IBD are at increased risk of 90-day medical complications, re-admissions, and ED visits. Due to its systemic nature, surgeons operating on these patients should be aware of the disease's extra-intestinal manifestations, and the potential postoperative risks in IBD patients. Providers should use this investigation when educating patients on potential risks of elective THA.

Crohn's disease is associated with higher rates of implant-related complications following primary total knee arthroplasty

INTRODUCTION

In Western countries, there has been a rise in the prevalence of Crohn's Disease (CD) and primary total knee arthroplasty (TKA). This study delves deeper into the effects of CD on TKA patients by examining (1) the length of in-hospital stay (LOS); (2) the rates of readmission; (3) complications related to implants; and (4) the costs associated with care.

METHODS

A retrospective analysis using the PearlDiver database was conducted, encompassing the time frame between January 1st, 2005 and March 31st, 2014, focusing on patients who underwent TKA and were either diagnosed with CD or not. Patients with CD were paired with control subjects at a 1:5 ratio based on age, gender, and medical comorbidities. The analysis comprised a total of 96,229 patients (CD = 16,039; non-CD = 80,190).

RESULTS

Patients with CD had a notably longer hospital stay (3 v. 2 days, p < 0.0001) and faced significantly higher rates of 90-day readmissions and complications (19.80% v. 14.91%, OR: 1.40, p < 0.0001; 6.88% v. 4.88%, OR: 1.43, p < 0.0001 respectively). Additionally, CD patients incurred greater expenses on the surgery day ($18,365.98 v. $16,192.00) and within 90 days post-surgery ($21,337.46 v. $19,101.42).

CONCLUSION

This study demonstrates longer in-hospital LOS, higher rates of readmissions, implant-related complications, and costs of care among CD patients following primary TKA.

Influence of Inflammatory Bowel Disease on Patients Undergoing Primary Total Joint Arthroplasty: A Systematic Review and Meta-analysis of Cohort Studies

Background

Inflammatory bowel disease (IBD) is recognized as a global disease. Although IBD is commonly diagnosed in the young male population, it also occurs in patients aged >60 years. With the advent of an aging society, it is expected that an increasing number of patients with IBD will undergo total joint arthroplasty (TJA).

Purpose

To assess the impact of IBD on the risk of complications and revision as well as the length of stay (LOS) and treatment costs after TJA.

Study Design

Systematic review; Level of evidence, 4.

Methods

Utilizing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, articles were searched in the PubMed/MEDLINE, Embase, and Cochrane Library databases from the date of inception to August 31, 2022, using the following search terms: (1) "Inflammatory Bowel Diseases"[MeSH] and (2) "Arthroplasty, Replacement"[MeSH]. The study quality was scored according to the Newcastle-Ottawa Scale. A fixed-effects or random-effects model was used to calculate odds ratios or mean differences with 95% confidence intervals.

Results

Of 232 studies initially retrieved, 8 retrospective cohort studies consisting of 33,758 patients with IBD and 386,238 patients without IBD were included. Patients with IBD had a higher incidence of complications (P < .05), readmission and revision (P < .05), experienced a longer LOS (P < .01), and paid higher treatment costs after TJA compared with patients without IBD .

Conclusion

The results of our review demonstrated that IBD increased the risk of postoperative complications, prolonged the LOS, and increased treatment costs.

Inflammatory bowel disease is associated with an increased risk of adverse events in patients undergoing joint arthroplasty

Aims

The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD.

Methods

A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.

Results

Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care.

Conclusion

The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications.

The utility of machine learning algorithms for the prediction of patient-reported outcome measures following primary hip and knee total joint arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used as quality benchmark in total hip and knee arthroplasty (THA; TKA) due to bundled payment systems that aim to provide a patient-centered, value-based treatment approach. However, there is a paucity of predictive tools for postoperative PROMs. Therefore, this study aimed to develop and validate machine learning models for the prediction of numerous patient-reported outcome measures following primary hip and knee total joint arthroplasty.

METHODS

A total of 4526 consecutive patients (2137 THA; 2389 TKA) who underwent primary hip and knee total joint arthroplasty and completed both pre- and postoperative PROM scores was evaluated in this study. The following PROM scores were included for analysis: HOOS-PS, KOOS-PS, Physical Function SF10A, PROMIS SF Physical and PROMIS SF Mental. Patient charts were manually reviewed to identify patient demographics and surgical variables associated with postoperative PROM scores. Four machine learning algorithms were developed to predict postoperative PROMs following hip and knee total joint arthroplasty. Model assessment was performed through discrimination, calibration and decision curve analysis.

RESULTS

The factors most significantly associated with the prediction of postoperative PROMs include preoperative PROM scores, Charlson Comorbidity Index, American Society of Anaesthesiology score, insurance status, age, length of hospital stay, body mass index and ethnicity. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.83), calibration and decision curve analysis.

CONCLUSION

This study developed machine learning models for the prediction of patient-reported outcome measures at 1-year following primary hip and knee total joint arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four machine learning models, highlighting the potential of these models in clinical practice to inform patients prior to surgery regarding their expectations of postoperative functional outcomes following primary hip and knee total joint arthroplasty.

LEVEL OF EVIDENCE

Level III, case control retrospective analysis.

Inflammatory bowel disease is associated with increased complications after total knee arthroplasty

BACKGROUND

Few studies investigate the influence of inflammatory bowel disease (IBD) on complications following total knee arthroplasty (TKA). Therefore, we compared complications and readmissions frequencies after TKA in patients with Crohn's disease (CD) and ulcerative colitis (UC) to patients without IBD.

METHODS

A large administrative claims database was used to identify patients who underwent primary TKAs from 2010 to 2019 and had a diagnosis of IBD before TKA. Patients were stratified into two groups: those with CD (n = 8,369) and those with UC (n = 11,347). These patients were compared a control of 1.3 million patients without an IBD diagnosis. Chi-square and unadjusted odds ratios (OR) with 95% confidence intervals (CI) were used to compare complication frequencies. Multivariable logistic regression was used to evaluate independent risk factors for 90-day complications.

RESULTS

Compared to patients without IBD, patients with IBD were associated with higher unadjusted 90-day odds for Clostridium difficile infection (CDI) (CD: OR 2.81 [95% CI 2.17 to 3.63]; p < 0.001; UC: OR 3.01 [95% CI 2.43 to 3.72]; p < 0.001) and two-year periprosthetic joint infection (CD: OR 1.34 [95% CI 1.18 to 1.52]; p < 0.001; UC: OR 1.26 [95% CI 1.13 to 1.41]; p < 0.001). After controlling for risk factors like obesity, tobacco use, and diabetes, both types of IBD were associated with higher 90-day odds for CDI and PJI (p < 0.001 for all).

CONCLUSION

IBD is associated with higher 90-day postoperative CDI and PJI compared with patients without IBD. Providers should consider discussing these risks with patients who have a diagnosis of IBD.

Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn's Disease After Elective Surgery: Meta-Analysis

BACKGROUND

Postoperative complication rates in patients with inflammatory bowel disease (IBD) receiving preoperative biologics have been analyzed without considering the surgical context. Emergency surgery may be associated with an increased risk of infectious complications, compared to elective operations.

AIMS

To conduct a systematic review and meta-analysis investigating the relationship between preoperative biologic therapy and postoperative outcomes in Crohn's disease (CD) and ulcerative colitis (UC), focusing on elective surgery.

METHODS

Electronic databases were searched up to February 12, 2020, for studies of patients with IBD undergoing elective abdominal surgery receiving biologic therapy within 3 months before surgery compared to no therapy, or another biologic therapy. Certainty of evidence was evaluated using GRADE. The primary outcomes were the rate of infections and total complications within 30 days. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Thirty-three studies were included. Preoperative treatment with anti-tumor necrosis factor (TNF) therapy in patients with CD undergoing elective surgery was associated with increased odds of infection (OR 2.05; 95% CI 1.40-3.01), but not total complications (OR 1.03; 95% CI 0.71-1.51). In elective surgery for UC, preoperative anti-TNF therapy was not associated with infectious (OR 1.03; 95% CI 0.34-3.07) or total complications (OR 0.67; 95% CI 0.29-1.58). Limited data indicate that emergency surgery did not significantly affect the rate of complications.

CONCLUSIONS

Anti-TNF therapy prior to elective surgery may increase the odds of postoperative infection in CD, although the certainty of evidence is very low. More evidence is needed, particularly for newer biologics.

Inflammatory Bowel Diseases Increase the Risk of Periprosthetic Joint Infection

BACKGROUND

A large body of evidence is emerging to implicate that dysregulation of the gut microbiome (dysbiosis) increases the risk of surgical site infections. Gut dysbiosis is known to occur in patients with inflammatory bowel disease (IBD), allowing for translocation of bacteria across the inflamed and highly permeable intestinal mucosal wall. The null hypothesis was that IBD was not associated with an increased risk of periprosthetic joint infection (PJI) after primary total hip and knee arthroplasty.

METHODS

A matched cohort study was designed. The primary end point was the occurrence of PJI at 2 years postoperatively. The secondary end points were aseptic revisions at 2 years postoperatively, discharge to a rehabilitation facility, complications up to 30 days after total joint arthroplasty, and readmission up to 90 days after total joint arthroplasty. The International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to identify patients with IBD and the control cohort. A chart review was performed to confirm the diagnosis of IBD. Using our institutional database, 152 patients with IBD were identified and matched (3:1) for age, sex, body mass index, year of surgical procedure, Charlson Comorbidity Index, and involved joint with 456 patients without IBD undergoing total joint arthroplasty.

RESULTS

The cumulative incidence of PJI was 4.61% for the patients with IBD compared with 0.88% for the control cohort (p = 0.0024). When univariable Cox regression was performed, a diagnosis of IBD was found to be an independent risk factor for PJI (hazard ratio [HR], 5.44 [95% confidence interval (CI), 1.59 to 18.60]; p = 0.007) and aseptic revisions (HR, 4.02 [95% CI, 1.50 to 10.79]; p = 0.006). The rate of postoperative complications was also higher in patients with IBD.

CONCLUSIONS

Based on the findings of this study, it appears that patients with IBD are at higher risk for treatment failure due to PJI or aseptic loosening after primary total joint arthroplasty. The exact reason for this finding is not known, but could be related to bacterial translocation from the inflamed intestinal mucosa, the dysregulated inflammatory status of these patients, malnutrition, and potentially other factors. Some of the aseptic failures could be as a result of infection that may have escaped detection and/or recognition.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Crohn's Disease Increases In-Hospital Lengths of Stay, Medical Complications, and Costs of Care following Primary Total Knee Arthroplasty

The literature has shown an increase in prevalence of Crohn's disease (CD) within the United States alongside a concomitant rise in primary total knee arthroplasty (TKA) procedures. As such, with these parallel increases, orthopaedic surgeons will invariably encounter CD patients requiring TKA. Limited studies exist evaluating the impact of this disease on patients undergoing the procedure; therefore, this study endeavors to determine whether CD patients undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS), (2) medical complications, and (3) episode of care (EOC) costs. To accomplish this, a nationwide database was queried from January 1, 2005 to March 31, 2014 to identify patients undergoing TKA. The study group, patients with CD, was randomly matched to the controls, patients without CD, in a 1:5 ratio after accounting for age, sex, and medical comorbidities associated with CD. Patients consuming corticosteroids were excluded, as they are at risk of higher rates of adverse events following TKA. This query ultimately yielded a total of 96,213 patients, with 16,037 in the study cohort and 80,176 in the control one. The study compared in-hospital (LOS), 90-day medical complications, and day of surgery and total global 90-day EOC costs between CD and non-CD patients undergoing primary TKA. The results found CD patients undergoing primary TKA had significantly longer in-hospital LOS (4- vs. 3 days, p < 0.0001) compared with non-CD patients. CD patients were also found to have significantly higher incidence and odds of 90-day medical complications (25.31 vs. 10.75; odds ratio: 2.05, p < 0.0001) compared with their counterparts. Furthermore, CD patients were found to have significantly higher 90-day EOC costs ($15,401.63 vs. 14,241.15, p < 0.0001) compared with controls. This study demonstrated that, after adjusting for age, sex, and medical comorbidities, patients with CD have prolonged in-hospital LOS, increased medical complications, and higher EOC costs following primary TKA. Therefore, it establishes the importance for orthopaedists to adequately counsel CD patients of the potential complications and outcomes following their procedure.

The risk of revision following total hip arthroplasty in patients with inflammatory bowel disease, a registry based study

Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the intestinal tract and is associated with decreased bone mineral density. IBD patients are at higher risk of osteopenia, osteoporosis and fracture compared to non-IBD patients. The impact of IBD on the performance of orthopedic implants has not been well studied. We hypothesized that a history of IBD at the time of primary total hip arthroplasty (THA) would increase the risk of subsequent failure as assessed by revision surgery. A retrospective implant survival analysis was completed using the Swedish Hip Arthroplasty Registry and the Sweden National Patient Register. A total of 150,073 patients undergoing THA for osteoarthritis within an 18-year period were included in the study. THA patients with (n = 2,604) and without (n = 147,469) a history of IBD at the time of THA were compared with primary revision as the main endpoint and adjusted using sex, age category and comorbidity (Elixhauser scores) as covariates. We found that patients with a history of IBD had a relatively higher risk of revision surgery for septic causes while the non-IBD patients had a relatively higher risk of revision for aseptic causes (p = 0.004). Our findings suggest there may be an association between gut health and THA performance.

Crohn's Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty

BACKGROUND

As the incidence and prevalence of Crohn's disease continues to change worldwide, rates within North America have been increasing. The objective of this study was to evaluate whether patients who have Crohn's disease undergoing primary total hip arthroplasties have worse outcomes compared with matched cohorts. Specifically, we evaluated 1) medical complications, 2) in-hospital lengths of stay (LOS), and 3) costs of care.

METHODS

Two cohorts of patients who underwent primary total hip arthroplasties from January 1, 2005 to March 31, 2014 were identified from the Medicare claims of the PearlDiver platform. Cohorts were matched by age, sex, and following comorbidities-anemia, diabetes, hyperlipidemia, hypertension, malnutrition, pulmonary disease, and renal failure, yielding 55,361 patients within the study (n = 9229) and matching cohorts (n = 46,132). Outcomes assessed included 90-day medical complications, in-hospital LOS, and costs of care. A P-value less than .005 was considered statistically significant.

RESULTS

Patients with Crohn's disease were found to have significantly higher incidences and odds ratios of 90-day medical complications (30.2 vs 13.8; odds ratios: 2.2, P < .0001). They were also found to have significantly longer LOS (3.8- vs 3.6-days, P < .0001) and higher day of surgery ($12,662.00 vs 12,271.15, P < .0001) and 90-day episode costs ($16,933.18 vs $15,670.32, P < .0001).

CONCLUSION

Crohn's disease is associated with higher rates of medical complications, longer in-hospital LOS, and increased costs of care. This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications in these patients.

Prevalence and Associations of Avascular Necrosis of the Hip in a Large Well-characterized Cohort of Patients With Inflammatory Bowel Disease

OBJECTIVES

Avascular necrosis (AVN) is associated with significant morbidity potentially causing severe pain and disability; patients with inflammatory bowel disease (IBD) have a higher prevalence of AVN compared with non-IBD populations. The purpose of our study was to determine the prevalence of AVN in our IBD population and to evaluate these subjects for the presence of clinical characteristics associated with AVN on computed tomography (CT) imaging.

METHODS

In 1313 IBD patients with abdomen/pelvis CT scans, we identified 27 patients (2.1%) with CT findings consistent with AVN. Through historical chart review, we confirmed that most patients had prior exposure to steroids, although 2 patients had no documented steroid exposure at all.

RESULTS

We found that 59% of the concurrent radiology reports did not comment on the presence of AVN, suggesting that incidental CT findings of AVN among IBD patients are likely underreported. Notably, we found that 63% of these cases had documented complaints of low-back and/or hip pain. Using logistic regression, we found an association between anti-neutrophil cytoplasmic antibody-positive status across IBD (p = 0.007) and a smoking history in Crohn disease (p = 0.03) with the presence of AVN.

CONCLUSIONS

We found that a significant proportion of IBD patients with AVN are reported in their records as having hip or low-back pain, and review of CT imaging under dedicated bone windows may identify AVN among this population. Our findings also suggest that additional etiological factors, beyond corticosteroids, contribute to the development of AVN in IBD. Further investigation is warranted regarding the mechanisms associated with AVN in IBD.

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty

BACKGROUND

Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures.

METHODS

All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients.

RESULTS

Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period.

CONCLUSION

GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

Anti-Tumour Necrosis Factor Therapy for Inflammatory Bowel Diseases Do Not Impact Serious Infections after Arthroplasty

BACKGROUND AND AIMS

There is a paucity of data on the safety of joint replacement surgery in patients with inflammatory bowel disease [IBD], including those on tumour necrosis factor-alpha inhibitors [anti-TNF]. We explored the risk of serious infections in this population.

METHODS

A retrospective case-control study [2006-2014] was performed using the MarketScan Database. All patients aged 18-64 years with an International Classification of Diseases code for IBD and an IBD-specific medication, with ≥ 6 months of enrollment prior to hip, knee or shoulder replacement surgery, were included. Ten non-IBD controls were frequency-matched to each case on length of enrollment, year and the joint replaced. Primary outcome was serious infection [composite of joint infection, surgical site infection, pneumonia, sepsis] within 90 days of the operation. Cox proportional hazards models were used to assess the association of IBD and IBD medications with serious infection.

RESULTS

More patients with IBD [N = 1455] had serious infections than controls [3.2% vs 2.3%, p = 0.04], but not after controlling for comorbidities (hazard ratio [HR], 1.3; 95% confidence interval [CI], 0.95-1.76). Among IBD patients, corticosteroids were associated with increased risk of serious infection [HR, 4.6; 95% CI, 2.2-9.8; p < 0.01] while anti-TNFs were not. Opioids were also associated with increased risk of infection [HR, 1.5; 95% CI, 1.2-1.8; p < 0.01].

CONCLUSIONS

After controlling for comorbidities, IBD patients were not at increased risk of serious infection following joint replacement. Corticosteroids, but not anti-TNFs or immunomodulators, were associated with increased risk of serious infections in IBD patients.

The association of inflammatory bowel disease and immediate postoperative outcomes following lumbar fusion

BACKGROUND CONTEXT

The United States Centers for Disease Control and Prevention estimates the prevalence of inflammatory bowel disease (IBD) at more than 3.1 million people. As diagnostic techniques and treatment options for IBD improve, the prevalence of IBD is expected to increase. For spine surgeons, patients with IBD have a unique complication profile because patients with IBD may present with poor nutritional status and because the medications used to manage IBD have been associated with poor vertebral bone mineralization and immunosuppression. Presently, there are very limited data regarding perioperative outcomes among patients with IBD who undergo spinal surgery. The present study begins to address this knowledge gap by describing trends in patients with IBD undergoing lumbar fusion and by quantifying the association between IBD and immediate postoperative outcomes using a large, national database.

PURPOSE

To advance our understanding of the potential pitfalls and risks associated with lumbar fusion surgery in patients with IBD.

DESIGN/SETTING

Retrospective cross-sectional analysis.

PATIENT SAMPLE

The Nationwide Inpatient Sample (NIS) database was queried from 1998 to 2011 to identify adult patients (18+) who underwent primary lumbar fusion operations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding.

OUTCOME MEASURES

Incidence of lumbar fusion procedures, prevalence of IBD, complication rates, length of stay, and total hospital charges.

METHODS

The annual number of primary lumbar fusion operations performed between 1998 and 2011 was obtained from the NIS database. Patients younger than 18 years of age were excluded. The prevalence of IBD in this population (both Crohn disease and ulcerative colitis) was determined using ICD-9-CM codes. Logistic regression models were estimated to determine the association between IBD and the odds of postoperative medical and surgical complications, while controlling for patient demographics, comorbidity burden, and hospital characteristics. The complex survey design of the NIS was taken into account by clustering on hospitals and assuming an exchangeable working correlation using the discharge weights supplied by the NIS. We accounted for multiple comparisons using the Bonferroni correction and an alpha level for statistical significance of . 0028.

RESULTS

The prevalence of IBD is increasing among patients undergoing lumbar fusion, from 0.21% of all patients undergoing lumbar fusion in 1998 to 0.48% of all patients undergoing lumbar fusion in 2011 (p<.001). The odds of experiencing a postoperative medical or surgical complication were not significantly different when comparing patients with IBD with control patients without IBD after controlling for patient demographics, comorbidity burden, and hospital characteristics (adjusted odds ratio=1.1, 95% confidence interval [CI] 0.99-1.3, p=.08). On multivariable analysis, the presence of IBD in patients undergoing lumbar fusion surgery was associated with longer length of stay and greater hospitalization charges.

CONCLUSIONS

Among patients who underwent lumbar fusion, IBD is a rare comorbidity that is becoming increasingly more common. Importantly, patients with IBD were not at increased risk of postoperative complications. Spine surgeons should be prepared to treat more patients with IBD and should incorporate the present findings into preoperative risk counseling and patient selection.

Hospital costs, length of stay and prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease

AIM

To examined the prevalence of hip and knee arthroplasty in patients with inflammatory bowel disease (IBD) by comparing the diagnostic codes for these procedures in patients with IBD and a control group of patients.

METHODS

The National Inpatient Sample database (NIS) is part of the Healthcare Cost and Utilization Project (HCUP), the largest publicly available inpatient healthcare database in the United States. The NIS samples about 20% of discharges from all community hospitals participating in HCUP, representative of more than 95% of the United States population, with approximately 7000000 hospitalizations reported annually. NIS contains data on diagnoses, procedures, demographics, length of stay (LOS), co-morbidities and outcomes. ICD-9-CM diagnostic codes for primary hospitalizations for arthroplasty of the hip or knee with a co-diagnosis of IBD [combining both Crohn's disease (CD) and ulcerative colitis (UC)] were used to identify study subjects for cost and LOS analysis for NIS from 1999-2012. Statistical analysis: 1: 2 propensity score matching between IBD vs a control group based on following factors: Patient age, gender, race, total co-morbidities, # of procedures, admission type, insurance, income quartiles, and hospital bed size, location and hospital teaching status. Categorical variables were reported as frequency and compared by χ2 tests or Fisher's exact tests. Individual 1:3 matching was also performed for patients carrying diagnostic codes for CD and for patients with the diagnostic code for UC. After matching, continuous variables were rcompared with Wilcoxon signed rank or Paired T-tests. Binary outcomes were compared with the McNemar's test. This process was performed for the diagnosis of hip or knee arthroplasty and IBD (CD and UC combined). Prevalence of the primary or secondary diagnostic codes for these procedures in patients with IBD was determined from NIS 2007.

RESULTS

Costs and mortality were similar for patients with IBD and controls, but LOS was significantly longer for hip arthroplasties patients with IBD, (3.85 +/-2.59 d vs 3.68 +/-2.54 d, respectively, P = 0.009). Costs, LOS and survival from the procedures was similar in patients with CD and UC compared to matched controls. These results are shown in Tables 1-10. The prevalence of hip arthroplasty in patients with IBD was 0.5% in 2007, (170/33783 total patients with diagnostic codes for IBD) and was 0.66% in matched controls (P = 0.0012). The prevalence of knee arthroplasty in patients with IBD was 1.36, (292/21202 IBD patients) and was 2.22% in matched controls (P < 0.0001).

CONCLUSION

Costs and mortality rates for hip and knee arthroplasties are the same in patients with IBD and the general population, while a statistical but non-relevant increase in LOS is seen for hip arthroplasties in patients with IBD. Compared to the general population, arthroplasties of the hip and knee are less prevalent in hospitalized patients with IBD.