Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement

Predictive analysis of economic and clinical outcomes in total knee arthroplasty: Identifying high-risk patients for increased costs and length of stay

PURPOSE

The purpose of this study was to predict high-risk patients who experience significant increases in hospital charges and length of stay (LOS) following specific postoperative complications.

METHODS

This study analyzed over two million patients from the Nationwide Inpatient Sample database undergoing elective total knee arthroplasty (TKA) for primary osteoarthritis. Baseline demographics, clinical characteristics and incidence of postoperative complications were examined. A neural network model was utilized to predict high-risk patients who fall into the top 25% for both LOS and total hospital charges after complications such as sepsis or surgical site infection (SSI).

RESULTS

The most common complications were blood loss anaemia (14.6%), acute kidney injury (1.6%) and urinary tract infection (0.9%). Patients with complications incurred significantly higher total charges (mean $66,804) and longer LOS (mean 2.9 days) compared to those without complications (mean $58,545 and 2.1 days, respectively). The neural network model demonstrated strong predictive performance, with an area under the curve of 0.83 for the training set and 0.78 for the testing set. Key complications like sepsis and SSIs significantly impacted hospital charges and LOS. For example, a 57-year-old patient with diabetes and sepsis had a 100% probability of being in the top 25% for both total charges and LOS.

CONCLUSION

Postoperative complications in TKA patients significantly increase hospital charges and LOS. The neural network model effectively predicted high-risk patients after specific complications occurred, offering a potential tool for improving patient management and resource allocation.

LEVELS OF EVIDENCE

Level III.

Outcomes following total shoulder arthroplasty in patients with systemic lupus erythematosus

BACKGROUND

Total shoulder arthroplasty (TSA) is a common procedure that may be considered for patients with glenohumeral osteoarthritis. Patients undergoing this procedure may be afflicted by comorbid conditions, such as systemic lupus erythematosus (SLE), which may impact odds of various postoperative complications.

METHODS

Adult patients with and without SLE who underwent TSA (anatomic or reverse) were queried from the January 2010 to October 2022 PearlDiver M165 database. Patients with and without SLE were matched (1:4) based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and 5-year implant survival were assessed and compared with multivariable analysis. Subanalyses were done for SLE patients with and without a prescription of immunomodulatory therapy (IMT; corticosteroids, hydroxychloroquine, and/or biologics) within 90 days before surgery and compared to non-SLE patients with multivariable analyses. Lastly, SLE patients with and without a 90-day history of IMT were directly compared with multivariate logistic regression. A Bonferroni correction was applied to univariable analyses and multivariable regressions.

RESULTS

Of 211,832 TSA patients identified, SLE was noted for 2228 (1.1%). After matching, 8261 patients without SLE and 2085 patients with SLE were selected. SLE patients were at an increased odds of 90-day aggregated events including severe (odds ratio [OR] = 3.50), minor (OR = 3.13), all (OR = 2.35), and orthopedic-related (OR = 1.41) adverse events (P < .0030 for all). There was no difference in 5-year implant survival. Of those with SLE, IMT medications were being received by 1267 (60.8%). Any, severe, minor, and orthopedic 90-day adverse events were significantly elevated for both those with and without IMT relative to those without SLE (P < .0030 for all except for orthopedic adverse events for those not on IMT, which were not significant). Relative to those not on IMT medications, those on IMT medications were at significantly higher odds of any, severe, minor, and orthopedic adverse events.

CONCLUSION

Following TSA, patients with SLE were found to be at an increased odds of 90-day adverse events but not of 5-year revisions. Furthermore, those on IMT medications were at higher risk of any, severe, minor, and orthopedic adverse events compared to those who were not on these medications. These findings may help with patient counseling and surgical planning when those with SLE are considered for TSA.

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

Background

Arthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and long-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature.

Methods

Patients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology codes. The exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched in a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. 1-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test.

Results

In total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354, respectively. Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (P < .0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (P < .0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery.

Discussion and Conclusion

Fibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in 1-year revisions.

Emergency Department Visits Following Supracondylar Humerus Fractures

INTRODUCTION

Pediatric supracondylar humerus fractures are common and the most frequent pediatric fracture to require surgical intervention. After initial management, emergency department (ED) visits subsequent to this injury/surgery are not well characterized, but are of clinical interest.

METHODS

Pediatric patients (age >1 ​​​​​​y old and <13 y old) with supracondylar humerus fractures were identified from the 2010 to 2021 PearlDiver M157 administrative database. These patients were stratified based on whether they visited the emergency department at least once within 90 days after their initial injury diagnosis/management. The timing of visits and reasons were determined, and predictive factors were assessed with multivariate logistical regression.

RESULTS

A total of 92,994 fractures were identified for which post-injury/post-operative ED visits were noted for 10,325 patients (11.1%). Nearly half of all ED visits occurred within the 2 weeks immediately after the fracture (46.1%), of which 54.7% of visits were not directly related to the elbow. On multivariate analysis, patients who utilized the ED after initial management of pediatric supracondylar humerus fracture were of greater odds ratio (OR) in decreasing order to have: had a history of ED visits before their initial injury (OR: 2.69), be diabetic (OR: 1.81), had surgical intervention for their fracture (OR:1.58), be obese (OR: 1.57), have asthma (OR:1.55), have Medicaid insurance (OR: 1.29), and be younger (OR: 1.11 per year decrease) ( P <0.001 for all).

DISCUSSION

In the 90 days after pediatric supracondylar humerus fracture, more than 1 in 10 patients visited the ED. This data highlight the need for close following of such patients after their injury/surgery and suggests risk factors for which patients such quality improvement measures should be focused.

LEVEL OF EVIDENCE

III.

Cefazolin Alone Versus Cefazolin With Tobramycin or Gentamicin as Intraoperative Antibiotic Prophylaxis for Total Joint Arthroplasty

Background

Prosthetic joint infection is a serious complication of total knee arthroplasty (TKA) and total hip arthroplasty (THA). While cefazolin is the standard prophylactic antibiotic, some groups have considered adding aminoglycosides (gentamycin or tobramycin) to this regimen.

Methods

Adult primary THA and TKA patients were identified from 2010-2021 Q1 PearlDiver M151 database. Inclusion criteria were activity in the database ≥ 90 days postoperative and no infectious, neoplastic, or traumatic diagnoses within 90 days preoperative. Intraoperative antibiotic prophylaxis regimens were determined using Current Procedural Terminology J codes. For both THA and TKA, 2 subcohorts were created: (1) Patients who received cefazolin alone and (2) cefazolin and tobramycin or gentamicin. Differences in 90-day postoperative adverse outcomes were assessed with multivariable logistic regression controlling for age, sex, and Elixhauser Comorbidity Index. Five-year implant survival was assessed using Kaplan-Meier analysis and log-rank tests.

Results

For THA, 32,882 patients were identified, prophylactic cefazolin alone was given to 30,527 (92.8%), and cefazolin + gentamicin/tobramycin was given to 2355 (7.2%). For TKA, 119,611 patients were identified, prophylactic cefazolin alone was given to 110,469 (92.4%), and cefazolin + gentamicin/tobramycin was given to 9142 (7.6%). Overall SSI rate for THA was 1.1% and for TKA 0.8%. For both THA and TKA, antibiotic subgroups were clinically similar with regard to age, sex, and Elixhauser Comorbidity Index. On univariable and multivariable analysis, no 90-day outcomes varied significantly. Five-year implant survivals were not significantly different.

Conclusions

For THA and TKA, cefazolin alone vs cefazolin + gentamicin/tobramycin were not found to have differences in rates of perioperative adverse outcomes (including SSI/prosthetic joint infection) or 5-year revision rates.

After Anterior Cruciate Ligament Surgery, Variables Associated With Returning to the Same Surgeon If a Subsequent Antrior Cruciate Ligament Surgery Is Needed?

INTRODUCTION

Anterior cruciate ligament reconstructions (ACLrs) unfortunately can require revision ACLr, or contralateral ACLr may be indicated (together subsequent ACLr). This study aimed to examine the rate of and factors associated with returning to the same surgeon.

METHODS

Patients who underwent ACLr and subsequent ACLr within 3 years were abstracted from the PearlDiver database. Patient factors and surgical factors were examined. Factors independently associated with changing the surgeon were examined.

RESULTS

Overall, 63,582 ACLr patients were identified with 2,823 (4.4%) having a subsequent ACLr. These subsequent ACLrs were performed by the same surgeon for 1,329 (47.1%) and by a different surgeon for 1,494 (52.9%). Factors independently associated with changing surgeons were 90-day adverse events after index surgery (odds ratio [OR] 1.95), longer time to second surgery (OR 1.61), and second surgery on the ipsilateral knee (OR 1.28). Notably, sex, comorbidity, depression, psychoses, and insurance plan were not correlated with choosing changing surgeons.

CONCLUSION

Over half of the patients who required a subsequent ACLr changed surgeons. Changing surgeons was associated with adverse events after index surgery, ipsilateral revisions, longer time to surgery, and patient age. However, there should be confidence that the other assessed factors were not associated with the decision to change surgeons.

Outcomes After Total Knee Arthroplasty in Patients With Autism: A Retrospective Database Study

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder associated with osteoarthritis for which total knee arthroplasty (TKA) may be considered. The safety and efficacy of TKA in patients with ASD had been poorly characterized.

METHODS

Total knee arthroplasty patients were identified using the M157 PearlDiver database. Patients with autism spectrum disorder were matched 1:4 with control TKA patients based on age, sex, and Elixhauser Comorbidity Index (ECI). 90-day adverse events were compared by multivariable regression, controlling for age, sex, and ECI. 5-year rates of revision were compared using Kaplan-Meier survival analyses.

RESULTS

Of 1,194,063 TKA patients, ASD was identified in 352 (0.02%). Patients with autism spectrum disorder were younger (60.0 vs. 65.8 years, P < 0.001) with higher ECIs (7.8 vs. 4.2, P < 0.001) than control patients. Patients with autism spectrum disorder had higher odds of aggregated adverse events driven by sepsis (odds ratio [OR] 3.11), pneumonia (OR 3.55), and urinary tract infection (OR 3.02) (P < 0.0036 for each). 5-year revision rates were not significantly different for the matched cohorts (P = 0.8000).

CONCLUSION

Total knee arthroplasty patients with ASD had elevated odds of several infectious adverse events and may warrant additional perioperative precautions. No notable differences were observed in most adverse outcomes investigated, nor in 5-year implant survival, suggesting that patients with ASD can safely be considered for TKA.

Patients With Diabetes on Sodium-Glucose Cotransporter-2 Inhibitors Undergoing Total Knee Arthroplasty Are at Increased Odds for a Number of Postoperative Adverse Events But Reduced Risk of Transfusion

INTRODUCTION

Diabetes mellitus (DM) is a common comorbidity in total knee arthroplasty (TKA) patients, which has been associated with multiple complications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are one class of medications recently approved to better manage DM. This study investigates the correlation of SGLT2i use on postoperative complications and revision rates for diabetic patients undergoing TKA.

METHODS

The M157 PearlDiver database was used to identify DM patients undergoing primary TKA. Those prescribed SGLT2i were identified and matched in 1:4 ratio with control DM patients based on age, sex, obesity diagnosis, and Elixhauser comorbidity index. Ninety-day adverse events and 5-year rates of revision were abstracted and compared by multivariable regression, controlling for age, sex, Elixhauser comorbidity index, long-term insulin use, obesity, metformin use, and active tobacco use.

RESULTS

A total of 164,474 TKA patients with DM were identified, of which SGLT2i were prescribed for 9,246 (5.6%). On multivariable analysis, SGLT2i use in DM patients was independently associated with higher odds of aggregated adverse events driven by myocardial infarction (odds ratio [OR] 2.40), sepsis (OR 1.81), urinary tract infection (OR 2.10), pneumonia (OR 1.87), and acute kidney injury (OR 1.33) but had lower odds of transfusion (OR 0.31) ( P < 0.0001 for each). On multivariable analysis, 5-year survival to revision TKA were not markedly different between the matched cohorts.

DISCUSSION

SGLT2i are being increasingly prescribed for DM patients undergoing TKA. Although they are associated with increased risk of multiple 90-day perioperative adverse outcomes, they are also associated with reduced incidence of blood transfusion. These results may guide surgical decision making and counseling for patients taking this group of medications and align with some prior studies related to glucagon-like protein-1 agonists.

Complication Rates Are Not Higher After Outpatient Versus Inpatient Fast-Track Total Knee Arthroplasty: A Propensity-Matched Prospective Comparative Study

BACKGROUND

This prospective study aimed to compare the complication rates and clinical outcomes of propensity-matched patients who received fast-track total knee arthroplasty (FT TKA) in outpatient versus inpatient settings.

METHODS

Patients (n = 629) who received FT TKA at various outpatient (n = 176) and inpatient (n = 462) surgery rates were prospectively followed until 90 days after surgery. The decision between inpatient versus outpatient FT TKA was made on a case-by-case basis, depending on consultation between the surgeon and patient. Complications were collected to distinguish between intraoperative complications, complications with no readmission, complications with readmission, and complications with reoperation. Propensity scores based on age, sex, body mass index, and the American Society of Anesthesiologists score were used to match outpatient to inpatient FT TKA. A cumulative incidence function was computed by taking the time to diagnose any postoperative complication in the first 90 days as the end point.

RESULTS

Propensity score matching (1:2 ratio) for comparison resulted in 173 outpatient FT TKAs and 316 inpatient FT TKAs. No significant differences were observed between outpatient versus inpatient FT TKA for intraoperative complication rates (2% in both groups). At 90-day follow-up, no significant differences were observed between outpatient versus inpatient FT TKA for total complications with no readmission (8.0 versus 7.9%), complications with readmission but no reoperation (1.1 versus 0.6%), and complications with reoperation (4.0 versus 4.4%). A comparison of postoperative complication diagnosis time using the cumulative incidence function revealed no significant differences between outpatient versus inpatient FT TKA.

CONCLUSIONS

The present study revealed that there were no differences in 90-day postoperative complication rates between outpatient and inpatient FT TKA and that there were also no differences in rates of intraoperative complications, readmissions, or reoperations. These findings may encourage hesitant surgeons to move toward outpatient TKA pathways, as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

LEVEL OF EVIDENCE

Level II.

Impact of Atopic Dermatitis (Eczema) and Its Treatment on the Risk of Adverse Events Following Total Knee Arthroplasty

BACKGROUND

Atopic dermatitis (AD), also known as eczema, is a highly prevalent, chronic inflammatory skin condition. The perioperative outcomes of patients with AD after total knee arthroplasty (TKA) have not been characterized.

METHODS

Adult patients who underwent TKA were identified in the PearlDiver administrative database. After matching based on patient characteristics, 90-day adverse events and 5-year revisions were compared by multivariable analyses and log-rank tests, respectively. Patients with atopic dermatitis were then stratified by medication status for repeated analysis between resultant subcohorts.

RESULTS

Relative to age, sex, and comorbidity matched patients without AD, those with AD had increased odds of aggregated adverse events (OR = 1.36), pneumonia (OR = 2.07), urinary tract infection (UTI, OR = 1.77), and emergency department (ED) visits (OR = 1.70) (P < 0.0001 for each). Those on medication for moderate-to-severe disease had similar associations as the primary analysis. Those not on medications were similar, but not found to have elevated odds of pneumonia. 5-year revisions were not markedly different.

CONCLUSION

TKA patients with AD were at increased odds of pneumonia, UTI, and ED visits, but these risks were not exacerbated by immunosuppressive medications. Surgeons who are managing patients with AD for TKA should be vigilant but reassured by overall similar 5-year survival to revision.

Total Hip Arthroplasty in Patients Who Have Factor V Leiden: Elevated Risks Isolated to Venous Thromboembolism Events

BACKGROUND

Total hip arthroplasty (THA) is a common procedure that requires consideration of preexisting comorbidities. Factor V Leiden (FVL), an inherited thrombophilia, is one such condition that predisposes patients to venous thromboembolism (VTE, deep vein thrombosis, and pulmonary embolism). The present study aimed to characterize the risks associated with FVL patients undergoing THA and evaluate the effect of VTE chemoprophylactic agents on these risks.

METHODS

A total of 544,022 adult patients who underwent primary THA for osteoarthritis indications between 2010 and October 2021 were identified in an administrative claims database. Of these, FVL was identified in 1,138 (0.21%). Patients who had and did not have FVL were matched at a 1:4 ratio (1,131 with FVL and 4,519 without FVL) based on age, sex, and Elixhauser comorbidity index. Univariable and multivariable analyses were assessed for 90-day complications. Implant survival at 5 years was assessed and compared with log-rank tests. The relative use of different chemoprophylactic agents, including aspirin, warfarin, heparin, or direct oral anticoagulant (DOAC), was assessed. Bleeding events and VTE were compared for those prescribed either aspirin or warfarin, heparin, or DOAC. A Bonferroni correction was applied.

RESULTS

On multivariable analysis, FVL patients were found to have increased odds of 90-day deep vein thrombosis (odds ratio (OR) = 9.20), pulmonary embolism (OR = 6.89), and aggregated severe and all adverse events (OR = 4.74 and 1.98, respectively), but not elevated risk of other perioperative adverse events or 5-year reoperations. More potent chemoprophylactic agents (warfarin, heparin, DOAC) reduced, but did not completely eliminate, the increased VTE risks (without increasing bleeding events).

CONCLUSIONS

This study quantified the significantly elevated VTE risk associated with FVL patients undergoing THA. The lack of difference in other specific adverse events and 5-year reoperations is reassuring. Clearly, chemoprophylactic agents are important in this population and may need further attention.

Corticosteroid Injections Administered Within 4 Weeks Prior to Hip Arthroscopy Are Associated With Higher Rates of Postoperative Infection

PURPOSE

To evaluate the association between the timing of intra-articular hip corticosteroid injections and the risk of postoperative infection in patients undergoing hip arthroscopy.

METHODS

The 2010-2021 PearlDiver M157 administrative claims database was queried for patients who underwent hip arthroscopy. Patients who received intra-articular corticosteroid injections within 12 weeks prior to arthroscopy were matched 1:1 to patients who did not receive such injections based on age, sex, and Elixhauser Comorbidity Index, as well as the presence of diabetes mellitus, hypertension, obesity, and tobacco use. Those with injections prior to arthroscopy were subdivided based on having received injections within 12 weeks prior to surgery. To verify that the corticosteroid injections and surgical procedures were conducted in the hip joint, Current Procedural Terminology codes were used. By use of Current Procedural Terminology and International Classification of Diseases (ninth revision and tenth revision) coding, postoperative surgical-site infection after corticosteroid injection was evaluated. The impact of the timing of preoperative corticosteroid injections on the incidence of postoperative infection was evaluated using multivariable logistic regression analysis.

RESULTS

A total of 12,390 hip arthroscopy cases were identified, including 3,579 patients who received corticosteroid injections 0 to 4 weeks prior to surgery; 4,759, within 4 to 8 weeks prior to surgery; and 4,052, within 8 to 12 weeks prior to surgery. Compared with controls, patients who received corticosteroid injections within 0 to 4 weeks preoperatively had a significantly higher rate of surgical-site infection (odds ratio, 2.43; P = .0001). No significant differences in infection rates were observed at the later time intervals (4-8 weeks or 8-12 weeks). Furthermore, in comparison to controls, patients who received corticosteroid injections had a significantly higher rate of wound dehiscence (odds ratio, 1.84; P = .0007).

CONCLUSIONS

Intra-articular corticosteroid injections within 4 weeks prior to hip arthroscopy were significantly associated with increased surgical-site infection rates after hip arthroscopy surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation

BACKGROUND

Von Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival.

METHODS

Adult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events.

RESULTS

Of 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006).

CONCLUSIONS

Patients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

Increased Risk of 90-Day Complications in Patients With Fibromyalgia Undergoing Total Shoulder Arthroplasty

INTRODUCTION

Anatomic and reverse total shoulder arthroplasties (TSAs) are effective treatment options for end-stage glenohumeral osteoarthritis. Those undergoing TSA may also have fibromyalgia, a musculoskeletal condition. However, the association of fibromyalgia with shorter and longer term outcomes after TSA has not been well characterized.

METHODS

Patients undergoing TSA for osteoarthritis indications were identified in the PearlDiver M165 database from January 2016 to October 2022. Exclusion criteria included age younger than 18 years, shoulder infection, neoplasm, or trauma within 90 days before surgery, and inactivity in the database within 90 days of surgery. Patients with fibromyalgia were matched in a 1:4 ratio to patients without based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were compared using univariable and multivariable analyses. Five-year revision-free survival was compared using the log-rank test.

RESULTS

Of 163,565 TSA patients, fibromyalgia was identified for 9,035 (5.52%). After matching, cohorts of 30,770 non-fibromyalgia patients and 7,738 patients with fibromyalgia were identified. Multivariable analyses demonstrated patients with fibromyalgia were at independently increased odds ratios (ORs) for the following 90-day complications (decreasing OR order): urinary tract infection (OR = 4.49), wound dehiscence (OR = 3.63), pneumonia (OR = 3.46), emergency department visit (OR = 3.45), sepsis (OR = 3.15), surgical site infection (OR = 2.82), cardiac events (OR = 2.72), acute kidney injury (OR = 2.65), deep vein thrombosis (OR = 2.48), hematoma (OR = 2.03), and pulmonary embolism (OR = 2.01) (P < 0.05 for each). These individual complications contributed to the increased odds of aggregated minor adverse events (OR = 3.68), all adverse events (OR = 3.48), and severe adverse events (OR = 2.68) (P < 0.05 for each). No statistically significant difference was observed in 5-year revision-free survival between groups.

DISCUSSION

This study found TSA patients with fibromyalgia to be at increased risk of adverse events within 90 days of surgery. Proper surgical planning and patient counseling are crucial to this population. Nonetheless, it was reassuring that those with fibromyalgia had similar 5-year revision-free survival compared with those without.

Patients With Cystic Fibrosis Undergoing Total Hip and Total Knee Arthroplasty Are at Increased Risk for Perioperative Complications

INTRODUCTION

Patients with cystic fibrosis (CF) are living longer and may be considered for total hip arthroplasty (THA) or total knee arthroplasty (TKA). Perioperative outcomes and implant survival after these procedures performed for those with CF have not been previously described.

METHODS

Using the M151 PearlDiver database, a large, national, administrative database, THA and TKA patients with and without CF were identified and matched 1:10 based on age, sex, and Elixhauser Comorbidity Index. Ninety-day perioperative outcomes and 2-year revision rates were assessed and compared with multivariable logistic regression.

RESULTS

For THA, 185 patients with CF were matched with 1,846 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including sepsis (odd radio [OR] 4.15), pneumonia (OR 3.40), pleural effusion (OR 2.77), minor events (OR 1.73), any adverse event (OR 1.64), urinary tract infection (UTI) (OR 1.63), and severe events (OR 1.60) ( P < 0.05 for each). For TKA, 505 patients with CF were matched with 5,047 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including pneumonia (OR 4.95), respiratory failure (OR 4.31), cardiac event (OR 2.29), minor events (OR 2.16), pleural effusion (OR 2.35), severe events (OR 2.06), urinary tract infection (OR 2.06), any adverse event (OR 1.96), atelectasis (OR 1.94), and acute kidney injury (OR 1.61) ( P < 0.05 for each). For both THA and TKA, those with CF were not at greater odds of 2-year rates of revision.

DISCUSSION

After THA and TKA, those with CF were found to be at increased odds of multiple defined postoperative events (predominantly infectious/pulmonary), but not 2-year revision rates. These findings help define areas in need of focused optimization and are reassuring regarding risks of surgery.

Anterior cervical decompression and fusion at one and two levels: trends and factors associated with structural allograft versus synthetic cages

Background

Following decompression in anterior cervical discectomy and fusion (ACDF), reconstruction is typically done with structural allograft or a synthetic cage. Relative trends and factors associated with utilizing these implants have not been well characterized.

Methods

The PearlDiver 2011 to 2021 M157 database was used to identify adult patients undergoing 1- or 2-level ACDF. The incidence of structural allograft versus synthetic cage utilized was compared by year. Patient factors predictive of synthetic cage use as the structural interbody for ACDF were assessed with multivariable analysis. Further, the use of anterior plates was trended to provide a measure of usage of stand-alone devices (this comparison was made beginning with 2016 based on coding limitations).

Results

Of 173,833 isolated 1- or 2-level ACDF cases identified, structural allograft was used for 63,029 (36.3%) and synthetic cages were used for 110,804 (63.8%). The use of synthetic cages increased from 51.1% of cases in 2011 to 75.8% of cases in 2021 (p < 0.0001). Independent clinical predictors of synthetic cage use were: older age (odds ratio [OR] 1.02 per decade), female sex (OR 1.04), and greater ECI (OR 1.09 per 2-point increase).Independent non-clinical predictors of synthetic cage use were: geographic region (Northeast OR 1.11, South OR 1.85, and West 2.08, each relative to Midwest), and provider specialty (orthopedic OR 1.06 relative to neurosurgeons). There was an increase in the percent of synthetic cases without separately coded plate ("stand-alone" interbody cages: 21.7% in 2016 to 35.3% in 2021, p < 0.001).

Conclusions

The usage of synthetic cages in 1- and 2- level ACDF has increased relative to structural allograft between 2011 and 2021 in the United States and more recently the use of "stand-alone" synthetic cages has been on the rise. Non-clinical as well as clinical factors were associated with implant choice, suggesting room for more consistent care algorithms.

Femoral Head Core Decompressions: Characterization of Subsequent Conversion to Total Hip Arthroplasty and Related Complications

BACKGROUND

Core decompression is a minimally invasive joint-preserving approach for early-stage osteonecrosis. The rate at which core decompression patients require total hip arthroplasty (THA) and rates of perioperative adverse outcomes have not been well-characterized.

METHODS

Adult patients undergoing core decompression and/or THA with osteonecrosis of the femoral head were identified from the 2015 to 2021 Q3 PearlDiver M157 database. Those undergoing THA without or with antecedent core decompression were identified and matched 4:1 on age, sex, and Elixhauser Comorbidity Index. Postoperative 90-day adverse events were compared with multivariable analysis. Five-year rates of revision, dislocation, and periprosthetic fracture were compared by the Kaplan-Meier curve and log-rank tests.

RESULTS

Core decompressions were identified for 3,025 patients of whom 387 (12.8%) went on to THA within 5 years (64% within the first year). The median time from initial core decompression to THA was 252 days. For THA, 26,209 adults were identified and 387 had prior core decompression. After matching, there were 1,320 without core decompression and 339 with core decompression. No statistically significant differences were observed in 90-day postoperative adverse events or 5-year rates of revision, dislocation, or periprosthetic fracture.

CONCLUSION

Core decompression may be an option for patients with osteonecrosis and does not seem to affect THA outcomes if required later.