Modifying Risk Factors for Total Joint Arthroplasty: Strategies That Work Nicotine

What Is the Fate of Total Joint Arthroplasty Patients Who Are Asked to Quit Smoking Prior to Surgery?

Background

Smoking is a known risk factor for complications following primary total joint arthroplasty (TJA). Little is known regarding the fate of patients who are asked to quit smoking before surgery. The purpose of this study was to evaluate the success of smoking cessation prior to primary TJA and the impact of smoking cessation on perioperative outcomes.

Methods

This is a retrospective review of patients who presented between 2008 and 2020 to a single academic medical center with a documented smoking history and were asked to quit smoking prior to receiving a date for primary TJA. The cohort was surveyed about smoking cessation, smoking history, use of quit aids, seeking surgery elsewhere due to the cessation policy, and postoperative complications. Descriptive statistics evaluated the relationship between demographics, smoking cessation, and postoperative complications.

Results

A total of 101 patients completed the survey with an overall response rate of 48%. Sixty-two percent of patients quit smoking before surgery, and 51% of these patients reported remaining smoke-free at 6 months postoperatively. The average time to quit before TJA was 45 days (range: 1-365 days), and 62% quit without quit aids. The wound complication/infection rate was significantly higher for patients who did not stop smoking prior to TJA (4 of 16; 27%) than for those who did quit prior to surgery (3 of 63; 5%; P = .02).

Conclusions

This study demonstrates that most patients (62%) will stop smoking, if required, prior to primary TJA. Furthermore, 51% of patients reported abstinence from smoking at 6 months following TJA. TJA appears to be an effective motivator for smoking cessation.

Level of Evidence

III (retrospective cohort study).

Tobacco Use Is Associated with More Severe Adverse Outcomes Than Morbid Obesity after Aseptic Revision TKA

The association of morbid obesity with increased revision total knee arthroplasty (rTKA) complications is potentially confounded by concurrent risk factors. This study was performed to evaluate whether morbid obesity was more strongly associated with adverse aseptic rTKA outcomes than diabetes or tobacco use history-when present as a solitary major risk factor. Demographic characteristics, surgical indications, and adverse outcomes (reoperation, revision, infection, and amputation) were compared between 270 index aseptic rTKA performed for patients with morbid obesity (n = 73), diabetes (n = 72), or tobacco use (n = 125) and 239 "healthy" controls without these risk factors at a mean 75.7 (range: 24-111) months. There was no difference in 2-year reoperation rate (17.8 vs. 17.6%, p = 1.0) or component revision rate (8.2 vs. 8.4%) between morbidly obese and healthy patients. However, higher reoperation rates were noted in patients with diabetes (p = 0.02) and tobacco use history (p < 0.01), including higher infection (p < 0.05) and above knee amputation (p < 0.01) rates in patients with tobacco use history. Multivariate analysis retained an independent association between smoking history and amputation risk (odds ratio: 7.4, 95% confidence interval: 1.7-55.2, p < 0.01). Morbid obesity was not associated with an increased risk of reoperation or component revision compared with healthy patients undergoing aseptic revision. Tobacco use was associated with increased reoperation and above knee amputation. Additional study will be beneficial to determine whether risk reduction efforts are effective in mitigating postoperative complication risks.

Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Smoking Cessation Disparities

Currently, 13.7% of the adult American population smokes cigarettes. Although rates of cigarette smoking have decreased over time, those of e-cigarette usage have increased. Smoking rates are highest in American Indians/Alaskan Natives and adults whose highest education level is a General Educational Development certificate, who live in rural American areas, and who have an annual household income of less than $35,000. After arthroplasty, smoking is linked to impaired wound healing, superficial and deep wound infections, and aseptic loosening. Patients who smoke should be strongly encouraged to stop and be supported with smoking cessation programs. Monitoring smoking cessation with cotinine levels may be inaccurate because variations have been noted in race, ethnicity, and sex. Confirmation of cessation as a hard stop to surgery could increase existing healthcare disparities. The role of the surgeon in encouraging patients to stop smoking, at least temporarily, before total joint arthroplasty cannot be overemphasized.

The Use of Artificial Neural Networks for the Prediction of Surgical Site Infection Following TKA

This is a retrospective study. Surgical site infection (SSI) is associated with adverse postoperative outcomes following total knee arthroplasty (TKA). However, accurately predicting SSI remains a clinical challenge due to the multitude of patient and surgical factors associated with SSI. This study aimed to develop and validate machine learning models for the prediction of SSI following primary TKA. This is a retrospective study for patients who underwent primary TKA. Chart review was performed to identify patients with superficial or deep SSIs, defined in concordance with the criteria of the Musculoskeletal Infection Society. All patients had a minimum follow-up of 2 years (range: 2.1-4.7 years). Five machine learning algorithms were developed to predict this outcome, and model assessment was performed by discrimination, calibration, and decision curve analysis. A total of 10,021 consecutive primary TKA patients was included in this study. At an average follow-up of 2.8 ± 1.1 years, SSIs were reported in 404 (4.0%) TKA patients, including 223 superficial SSIs and 181 deep SSIs. The neural network model achieved the best performance across discrimination (area under the receiver operating characteristic curve = 0.84), calibration, and decision curve analysis. The strongest predictors of the occurrence of SSI following primary TKA, in order, were Charlson comorbidity index, obesity (BMI >30 kg/m²), and smoking. The neural network model presented in this study represents an accurate method to predict patient-specific superficial and deep SSIs following primary TKA, which may be employed to assist in clinical decision-making to optimize outcomes in at-risk patients.

Time Trends in Patient Characteristics and In-Hospital Adverse Events for Primary Total Knee Arthroplasty in the United States: 2010-2017

Background

Perioperative care for total knee arthroplasty (TKA) has improved over time. We present an analysis of inpatient safety after TKA.

Methods

14,057 primary TKAs captured by the Medicare Patient Safety Monitoring System between 2010 and 2017 were retrospectively reviewed. We calculated changes in demographics, comorbidities, and adverse events (AEs) over time. Risk factors for AEs were also assessed.

Results

Between 2010 and 2017, there was an increased prevalence of obesity (35.1% to 57.6%), tobacco smoking (12.5% to 17.8%), and renal disease (5.2% to 8.9%). There were reductions in coronary artery disease (17.3% to 13.4%) and chronic warfarin use (6.7% to 3.1%). Inpatient AEs decreased from 4.9% to 2.5%, (P < .01), primarily driven by reductions in anticoagulant-associated AEs, including major bleeding and hematomas (from 2.8% to 1.0%, P < .001), catheter-associated urinary tract infections (1.1% to 0.2%, P < .001), pressure ulcers (0.8% to 0.2%, P < .001), and venous thromboembolism (0.3% to 0.1%, P = .04). The adjusted annual decline in the risk of developing any in-hospital AE was 14% (95% confidence interval [CI] 10%-17%). Factors associated with developing an AE were advanced age (odds ratio [OR] = 1.01, 95% CI 1.00-1.01), male sex (OR = 1.21, 95% CI 1.02-1.44), coronary artery disease (OR = 1.35, 95% CI 1.07-1.70), heart failure (OR = 1.70, 95% CI 1.20-2.41), and renal disease (OR = 1.71, 95% CI 1.23-2.37).

Conclusions

Despite increasing prevalence of obesity, tobacco smoking, and renal disease, inpatient AEs after primary TKA have decreased over the past several years. This improvement is despite the increasing complexity of the inpatient TKA population over time.

Perioperative Laboratory Markers as Risk Factors for Surgical Site Infection After Elective Hand Surgery

PURPOSE

The purpose of this study was to test the null hypothesis that there is no association between perioperative laboratory markers (serum albumin and hemoglobin A1c [HbA1c]) and incidence of surgical site infection (SSI) after soft tissue upper extremity surgery.

METHODS

We analyzed patient-level data from a large, insurance-based database containing supplemental laboratory results. We identified patients undergoing soft tissue upper extremity surgery (defined as carpal tunnel release, trigger finger release, wrist ganglion excision, cubital tunnel release, Dupuytren partial fasciectomy, or first dorsal compartment release) with serum albumin or HbA1c measurements within 90 days of surgery. We stratified patients into cohorts based on serum albumin concentration (<3.5 g/dL) and HbA1c (≥7%) thresholds. The primary outcome was incidence of SSI within 30 days following surgery. We constructed multivariable logistic regression models to adjust for patient demographics and baseline comorbidities using the Elixhauser comorbidity index.

RESULTS

Patients with hypoalbuminemia experienced an SSI incidence of 3.5% compared to 0.9% in patients with normal serum albumin. In multivariable analysis, the odds ratio of SSI with hypoalbuminemia was 3.32 (95% CI, 2.32-4.65). Patients with HbA1c ≥ 7% experienced an SSI incidence of 1.1% compared to 0.7% in patients with HbA1c < 7%. Multivariable analysis revealed odds ratios for SSI of 1.47 (95% CI, 1.02-2.11) in patients with HbA1c ≥ 7% compared to those with HbA1c < 7%.

CONCLUSIONS

Hypoalbuminemia and elevated HbA1c (in patients with diabetes) are risk factors for SSI within 30 days following soft tissue upper extremity surgery. Preoperative measurement of these laboratory markers may be a useful tool for risk stratification and identification of high-risk patients for nutritional or glycemic optimization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?

Background

There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA.

Methods

The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m² and age of 72 years, and 60% of whom were female.

Results

We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m², tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001).

Conclusions

Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient.

Level of Evidence

IV.

Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?

BACKGROUND

Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m², had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups.

RESULTS

Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m², albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality.

CONCLUSION

Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization.

LEVEL OF EVIDENCE

Retrospective cohort study, level IV.

Staged Bilateral Total Knee Arthroplasty: Increased Risk of Recurring Complications

BACKGROUND

As the demand for knee arthroplasty increases, risk assessment and counseling are critical for optimal patient outcomes perioperatively. The purpose of this study was to determine if specific complications occurring after unilateral knee replacement predict the risk of recurrence after a staged replacement of the contralateral knee for patients with bilateral symptomatic disease.

METHODS

Linked, nationwide data from the U.S. Hospital Cost and Utilization Project from 2005 to 2014 were used to measure the occurrence of complications after the first and second procedures in staged bilateral total knee arthroplasties (TKAs). Odds ratios (ORs) and conditional probabilities were determined to assess whether having a specific complication after the first TKA increased the chance that the same complication occurred after the second procedure.

RESULTS

A total of 36,278 patients who underwent staged bilateral TKAs were analyzed. All complications occurring after the first arthroplasty were associated with both a significantly increased probability and odds of recurrence following the second arthroplasty. These included myocardial infarction (OR, 56.63 [95% confidence interval (CI), 18.04 to 155.44]; p < 0.001), ischemic stroke (OR, 41.38 [95% CI, 1.98 to 275.82]; p = 0.03), other cardiac complications (OR, 7.73 [95% CI, 4.24 to 14.11]; p < 0.001), respiratory complications (OR, 8.58 [95% CI, 2.85 to 23.17]; p = 0.002), urinary complications (OR, 11.19 [95% CI, 5.44 to 22.25]; p = 0.001), hematoma (OR, 15.05 [95% CI, 7.90 to 27.27]; p < 0.001), deep vein thrombosis (OR, 7.40 [95% CI, 5.37 to 10.08]; p < 0.001), and pulmonary embolism (OR, 11.00 [95% CI, 5.01 to 23.92]; p < 0.001).

CONCLUSIONS

Medical complications that occur postoperatively after TKA are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee. Although overall complication rates remain low, patients who develop these medical complications after the first replacement should be counseled on their increased risk profile prior to the contralateral surgical procedure.

LEVEL OF EVIDENCE

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

Smoking and Total Hip Arthroplasty: Increased Inpatient Complications, Costs, and Length of Stay

BACKGROUND

Smoking is a potentially modifiable risk factor that may impact the overall outcomes of total hip arthroplasty (THA). In an era of bundled payments for THA, the purpose of this study was to evaluate, on a national level, the inpatient complications and additional costs of smokers undergoing THA.

METHODS

The Nationwide Inpatient Sample was used to identify all primary elective THAs performed in the United States in 2014. This cohort was further stratified by smoking status. Inpatient hospital characteristics, costs, and complications rates were assessed.

RESULTS

The Nationwide Inpatient Sample had 63,446 admissions recorded for primary THAs in 2014, corresponding to an estimated 317,230 cases nationwide. The smoking rate was 20.7%. Smokers were slightly yet significantly younger than nonsmokers (63.5 years vs 64.8 years; P < .0001). The smoking group had a significantly longer hospital stay and higher total hospital costs (both P < .0001). After using a multivariable logistic model adjusting for age, gender, and comorbidities, smokers were found to have a significantly higher odds ratio (OR [95% confidence interval {CI}]) for myocardial infarction (15.5 [5.0-47.5]), cardiac arrest (10.1 [2.2-47.6]), pneumonia (4.7 [2.4-9.1]), urinary tract infection (1.9 [1.4-2.7]), sepsis (13.1 [3.5-49.0]), acute renal failure (2.9 [2.2-3.7]), discharge to a skilled nursing facility (1.3 [1.2-1.4]), and mortality (11.7 [2.0-70.5]).

CONCLUSIONS

Smoking remains a highly prevalent and important risk factor for complications in elective primary THA in the United States. Patients who smoke have a significantly higher rate of complications and generate significantly higher postoperative inpatient costs. These findings are important for risk stratification, bundled payment considerations, as well as perioperative patient education and intervention.

2019 Chitranjan S. Ranawat Award: Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor

AIMS

To date, no study has demonstrated an improvement in postoperative outcomes following elective joint arthroplasty with a focus on nutritional intervention for patients with preoperative hypoalbuminaemia. In this prospective study, we evaluated differences in the hospital length of stay (LOS), rate of re-admission, and total patient charges for a malnourished patient study population who received a specific nutrition protocol before surgery.

PATIENTS AND METHODS

An analytical report was extracted from the electronic medical record (EMR; Epic, Verona, Wisconsin) of a five-hospital network joint arthroplasty patient data set between 2014 and 2017. A total of 4733 patients underwent joint arthroplasty and had preoperative measurement of albumin levels: 2220 at four hospitals and 2513 at the study hospital. Albumin ≤ 3.4 g/l, designated as malnutrition, was found in 543 patients (11.5%). A nutritional intervention programme focusing on a high-protein, anti-inflammatory diet was initiated in January 2017 at one study hospital. Hospital LOS, re-admission rate, and 90-day charges were compared for differential change between patients in study and control hospitals for all elective hip and knee arthroplasty patients, and for malnourished patients over time as the nutrition intervention was implemented.

RESULTS

Malnourished patients with nutritional intervention at the study hospital had shorter hospital LOS beginning in 2017 than malnourished patients at control hospitals during the same period (p = 0.04). Similarly, this cohort had significantly lower primary hospitalization charges, charges associated with hospital re-admissions, and 90-day total charges (p < 0.001). Inclusion of covariant potential confounders (age, anaemia, diabetes, and obesity) did not alter the conclusions of the primary statistical analysis.

CONCLUSION

Joint arthroplasty outcomes were positively affected in study patients with low albumin when a high-protein, anti-inflammatory diet was encouraged. Elective surgery was neither cancelled nor delayed with a malnutrition designation. While the entire network population experienced improved postoperative outcomes, malnourished control patients did not experience this improvement. This study demonstrated that education on malnutrition can benefit patients. Cite this article: Bone Joint J 2019;101-B(7 Supple C):17-21.

Smoking Cessation Before and After Total Joint Arthroplasty-An Uphill Battle

BACKGROUND

Patients actively smoking at the time of primary total joint arthroplasty (TJA) are at increased risk of perioperative complications. Employing strategies for smoking cessation has therefore become routine. A potential benefit of cessation in anticipation of TJA may be long-term cessation. However, success rates and the longevity of successful smoking cessation attempts before TJA have yet to be presented.

METHODS

Our institution's total joint registry documents self-reported smoking status. As such, all patients who underwent TJA from 2007 to 2018 were identified and grouped as nonsmokers, smokers (regularly smoking within 1 year before surgery), and former smokers (those who quit smoking within 1 year before surgery). Thereafter, postoperative smoking status was assessed with special attention to former smokers to see who remained smoke-free.

RESULTS

From the 28,758 primary TJAs identified, 91.3% (26,244) were nonsmokers, 7.3% (2109) were smokers, and 1.4% (405) had quit smoking before surgery. Among former smokers, 86% were abstinent 1 year postoperatively but only 45% were still abstinent 8 years postoperatively. Conversely, 7% of smokers at the time of surgery eventually quit and 6% of prior nonsmokers started smoking over the same time period.

CONCLUSION

Despite concerted efforts to help patients stop smoking before TJA, 7.3% remain smokers. Among those who are successful, less than half (45%) remain smoke-free after surgery. Compared to current smokers, however, patients who managed to quit before surgery are more likely to remain smoke-free after surgery. These findings demonstrate the tremendous challenge smoking represents in contemporary TJA practices.

LEVEL OF EVIDENCE

Therapeutic level III.

Cotinine Testing Improves Smoking Cessation Before Total Joint Arthroplasty

BACKGROUND

Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at an increased risk of perioperative complications. Serum cotinine testing is a sensitive and specific method to verify abstinence from smoking and may therefore improve a patient's chance of smoking cessation. The primary purpose of this study was to assess whether cotinine testing improves the self-reported quit rate among smokers before TJA.

METHODS

Our hospital performs a high volume of TJAs and documents smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through an institutional total joint registry. As part of a retrospective analysis, this information was used to identify all self-reported smokers (regularly cigarette smoking within 1 year of TJA) who underwent unilateral TJA from 2007 to 2018. The cohort had a mean age of 66 years, 55% were female, and the mean body mass index was 31 kg/m². Patients whose serum cotinine was obtained within 1 month before surgery were then separated from the cohort and compared to the smokers who did not undergo cotinine testing.

RESULTS

Of the 28,758 primary TJAs identified, 8.8% (2514) were smokers. Serum cotinine testing was obtained on 103 of these patients. The abstinence rate (by means of self-reporting) before surgery significantly improved from 15.8% to 28.2% in the untested vs cotinine-tested groups, respectively (P = .005). Among all patients who underwent cotinine testing, 77% were negative (abstinent) and an additional 15% had cotinine levels between 3 and 8 ng/mL representing passive tobacco exposure. Among patients who stated they had quit smoking, 15% still had positive cotinine tests.

CONCLUSION

Smoking cessation remains a major challenge in contemporary TJA practices despite a concerted effort to help patients quit. Our findings suggest that cotinine testing significantly improves the self-reported quit rates of smokers before surgery and helps identify the 15% who falsely report abstinence to ensure appropriate counseling of inherent risks.

LEVEL OF EVIDENCE

Therapeutic level III.

Cost-Effectiveness of Preoperative Smoking Cessation Interventions in Total Joint Arthroplasty

BACKGROUND

Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear.

METHODS

Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis.

RESULTS

In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%.

CONCLUSION

Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA.

LEVEL OF EVIDENCE

Level II, economic and decision analyses.

Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

BACKGROUND

Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs.

METHODS

This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015).

RESULTS

The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m² or 35-40 kg/m² with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93).

CONCLUSION

In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis.

RECENT FINDINGS

Patients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed. Despite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.

Modifiable Risk Factors in Primary Joint Arthroplasty Increase 90-Day Cost of Care

BACKGROUND

Risk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care.

METHODS

An electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m²), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared.

RESULTS

Mean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor.

CONCLUSIONS

Medical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.

What is the Impact of Smoking on Revision Total Hip Arthroplasty?

BACKGROUND

There is a paucity of literature evaluating the impact of smoking on revision total hip arthroplasty (THA) outcomes. The purpose of this study was to identify the effect of smoking on complications after revision THA.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent revision THA between 2006 and 2014. Patients were divided into current smokers and nonsmokers. Each cohort was compared in terms of demographics, preoperative comorbidities, and operative time. Multivariate logistic regression analysis was utilized. Adjusted odds ratios (OR) for the outcomes of any wound complication, deep infection, and reoperation within 30 days of revision THA were calculated.

RESULTS

In total, 8237 patients had undergone a revision THA. Of these patients, 14.7% were current smokers and 85.3% were nonsmokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (4.1% vs 3.0%, P = .04), deep infection (3.2% vs 1.9%, P = .003), and reoperation (6.8% vs 4.8%, P = .003). Multivariate analysis controlling for confounding demographic, comorbidity, and operative variables identified current smokers as having a significantly increased risk of deep infection (OR, 1.58; 95% CI, 1.04-2.38) and reoperation (OR, 1.37; 95% CI, 1.03-1.85).

CONCLUSION

Smoking significantly increases the risk of infection and reoperation after revision THA. The results are even more magnified for revision procedures compared to published effects of smoking on primary THA complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.

Modifiable Risk Factors Are Common in Early Revision Hip and Knee Arthroplasty

BACKGROUND

Obesity, smoking, uncontrolled diabetes, and poor dental health are modifiable risk factors for revision total joint arthroplasty. To protect patients from revision surgery while also reducing cost, some joint arthroplasty practices use these conditions as contraindications until they are improved. However, this practice is variable among joint arthroplasty surgeons. We hypothesize that a relatively high rate of revision arthroplasty patients had modifiable risk factors at the time of primary surgery.

METHODS

A retrospective review of all revision total hip and knee arthroplasties performed at an academic, tertiary referral center within 2 years of primary surgery was conducted. The presence of body mass index >40, hemoglobin A1c >8, poor dentition, and smoking status were obtained from the electronic medical record. Risk factors were described and compared between infected revisions and noninfected revisions.

RESULTS

A total of 128 revision arthroplasties were performed at our institution in one year. And 23 of 57 (40.4%) total hip revision and 31 of 71 (43.7%) total knee revision patients had at least 1 modifiable risk factor. Infected hip revision patients were more likely to have increased body mass index compared to noninfected patients. Infected knee revision patients were more likely to smoke, have poor dentition, and have >1 contraindication compared to noninfected patients.

CONCLUSION

A high percentage of patients undergoing early revision arthroplasty had at least 1 modifiable risk factor for a primary joint arthroplasty. Joint arthroplasty surgeons may help reduce revision surgery through counseling and appropriate referral for modification of risk factors.

Smoking is associated with earlier time to revision of total knee arthroplasty

BACKGROUND

Smoking is associated with early postoperative complications, increased length of hospital stay, and an increased risk of revision after total knee arthroplasty (TKA). However, the effect of smoking on time to revision TKA is unknown.

METHODS

A total of 619 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to the patient smoking status. Smoking status was then analyzed for associations with time to revision TKA using a Chi square test. The association was also analyzed according to the indication for revision TKA.

RESULTS

Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to non-smokers (274/357, 77%, p=0.031). Smokers (37/41, 90%) have an increased risk of earlier revision for any reason compared to ex-smokers (168/221, 76%, p=0.028). Subgroup analysis did not reveal a difference in indication for revision TKA (p>0.05).

CONCLUSIONS

Smokers are at increased risk of earlier revision TKA when compared to non-smokers and ex-smokers. The risk for ex-smokers was similar to that of non-smokers. Smoking appears to have an all-or-none effect on earlier revision TKA as patients who smoked more did not have higher risk of early revision TKA. These results highlight the need for clinicians to urge patients not to begin smoking and encourage smokers to quit smoking prior to primary TKA.