Effects of Comorbidities on Pain and Function After Total Hip Arthroplasty

Influence of pre-operative co-morbidities on pain and function outcomes at 1 year after primary total knee arthroplasty

INTRODUCTION

Multimorbidity has been found to be associated with more pain and poorer function following total knee arthroplasty (TKA). We describe the relationship between both the total number of pre-operative co-morbidities, and individual co-morbidities, with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 months after TKR.

METHODS

We performed a secondary analysis on 290 participants from the Arthroplasty Pain Experience (APEX) trial, with seventeen imputations by Chained Equations. Using multivariable adjusted linear regression models, we analysed the relationship between total number of pre-operative co-morbidities, followed by individual co-morbidities, with WOMAC score at 12 months after randomisation.

RESULTS

Patients with ≥ 5 co-morbidities have worse outcomes compared to patients with 3 co-morbidities, scoring -9.6 points for function (95% CI -15.3 to -3.8), and -9.8 points for pain (95%CI -15.9 to -3.8). Patients reported worse pain with osteoporosis (-7.8 95%CI -14.1 to -1.6), peripheral vascular disease (-17.8 95%CI -34 to -1.8), depression (-9.8 95%CI -18.1 to -1.4), anxiety (-9.7 95%CI -18 to -1.4) or degenerative disc disease (-7.5 95%CI -13.3 to -1.7). Worse function was associated with osteoporosis (-7.1 95%CI -12.9 to -1.4), diabetes mellitus (-9.1 95%CI -15.6 to -2.6), anxiety (-8.1 95%CI -16 to -0.2) and degenerative disc disease (-8.6 95%CI -14.1 to -3.2).

CONCLUSION

Pre-operative multimorbidity is associated with worse outcomes after TKA. Patients with pre-operative osteoporosis, anxiety and degenerative disc disease had worse pain and function at 12-months. Surgeons may use these results during discussion with patients about their potential outcome after TKA.

State Health Care Regulations and Political Affiliation Associated With Total Hip Arthroplasty Prices Across the United States

BACKGROUND

Given that total hip arthroplasty (THA) is an elective procedure with rapidly increasing volumes (projected increase of 350% by 2050) and predictable costs, it is uniquely suited to serve as a proxy for assessing price transparency of hospital services. This study investigated the association between THA pricing and state characteristics, including political affiliation, Medicaid expansion status, certificate of need (CON) status, and gross domestic product per capita. North Carolina Area Deprivation Index (ADI) as well as urbanization are also considered. It was hypothesized that hospitals in states with Democratic partisanship, CON laws, and Medicaid expansion would exhibit lower prices.

METHODS

The THA price data were extracted using Current Procedural Terminology code 27130. The study included 2,226 hospitals nationwide. The median (interquartile range) price of THA across these hospitals was $12,465.46 ($6,864.69). The degree of state partisan lean was calculated by evaluating state characteristics during the 2020 election year, including presidential vote, senate majority, house majority, governor affiliation, and insurance commissioner affiliation. Multivariable regression models were used to assess the relationship between these factors and THA price.

RESULTS

Hospitals in Democratic-leaning states were associated with a significantly lower price of -$72.79 (P < 0.001). Medicaid expansion and CON status were also associated with a reduction in the price of -$491.39 (P < 0.0001) and -$546.73 (P < 0.0001), respectively. In North Carolina, an ADI > 85 was associated with a reduction in the price of -$3,672.60 (P = 0.0033), while urbanization was not significantly associated (P = 0.34).

CONCLUSIONS

Total hip arthroplasty (THA) prices are lower in states with Democratic leadership, Medicaid expansion, and CON laws. An ADI > 85 was also associated with reduced THA prices. These findings underscore the complexity of health care pricing and the important role state policies and socioeconomic factors play in determining costs.

LEVEL OF EVIDENCE

III.

Effect of Nationwide Postoperative Rehabilitation at Home Program after Lower Extremity Surgeries in Older and Younger People

BACKGROUND

A nationwide Rehabilitation at Home Care Pilot Program for patients undergoing lower extremity orthopedic surgeries has been ongoing since 2020. The program was designed to improve clinical outcomes through early mobilization and rehabilitation after discharge. This study aimed to analyze the interim data to assess its effectiveness and suggest improvements, particularly for older patients who are more vulnerable compared to younger patients.

METHODS

We analyzed the data of 872 patients from seven hospitals. Patients were divided into an older-age group (OG; ≥60 years) and younger-age group (YG; <60 years). The Berg Balance Scale (BBS) and Numeric Rating Scale (NRS) scores for pain were the main outcomes.

RESULTS

Participants were categorized into OG (n=801) and YG (n=71). The most common surgeries were knee joint replacement (63.7%) in OG and hip joint replacement in YG (77.5%). It took more days to enroll in the pilot program in OG (4.4 days) than YG (3.2 days). OG showed less improvement in BBS than YG for all surgeries (23.3 vs. 31.9) and hip joint surgery (19.8 vs. 33.5). In patients with hip joint replacement in OG, those with a higher number of comorbidities (≥3) showed less BBS improvement than those with fewer comorbidities (<3). In the pain domain, NRS scores decreased in both groups.

CONCLUSION

The postoperative rehabilitation education program appeared to be effective in improving physical function and reducing pain severity, though the improvement was less obvious in older patients who may require a more comprehensive approach compared to younger patients.

Perioperative Geriatrician Assessment Is Associated with a Lower Risk of Emergency Department Visits After Total Joint Arthroplasty

BACKGROUND

Previous research has underscored the benefits of geriatrician consultation in improving outcomes for older patients undergoing hip fracture repair, highlighting enhanced functional outcomes and reduced morbidity. However, the impact of geriatrician care in outcomes for patients undergoing elective total joint arthroplasty (TJA) has yet to be described. We aimed to determine whether preoperative or postoperative geriatrician involvement was associated with differences in the length of hospital stay and emergency department (ED) visits after TJA.

METHODS

This retrospective cohort study screened the medical records of patients ≥65 years of age undergoing primary elective TJA in a network of tertiary hospitals. Geriatrician consultations occurring within a period spanning 90 days before to 90 days after TJA were recorded. Bivariate analysis and multivariable regression models were used to assess the relationship between receiving these consultations and changes in the length of stay and ED visits.

RESULTS

A total of 16,076 patients undergoing primary TJA were included. Of these surgical procedures, 9,677 (60.2%) were total knee arthroplasties and 6,087 (37.9%) were total hip arthroplasties; 1,416 (8.8%) of cases had geriatrician visits. Patients had lower odds of requiring postoperative ED visits when they had at least 1 geriatrician appointment within the week preceding an arthroplasty (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.68 to 0.99]; p = 0.005). This effect was most notable for 65-year-old patients (OR, 0.66 [95% CI, 0.45 to 0.98]).

CONCLUSION

This study reports promising evidence supporting the benefits of perioperative geriatrician visits on TJA outcomes. Preoperative visits were shown to be associated with decreased odds of ED visits after TJA in patients for up to 90 days postoperatively. Thus, geriatrician involvement in elective TJAs has the potential to improve outcomes and reduce morbidity and costs for patients and reduce costs for surgeons and institutions.

LEVEL OF EVIDENCE

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

Incidence and risk factors for unplanned readmission after total hip arthroplasty for osteonecrosis of the femoral head

Objective

To investigate the incidence, primary causes, and risk factors for unplanned readmissions within one year after the first primary total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH).

Methods

Data were retrospectively collected from patients who had undergone the first primary THA for ONFH at two tertiary hospitals between January 2021 and December 2022, with complete 1-year follow-up assessments. Patients who experienced an unplanned readmission within 1 year were classified as the readmission group, while the others as the non-readmission group. The incidence rate and primary causes of unplanned readmission were determined, and the risk factors were identified through univariate and multivariate analyses.

Results

A total of 594 eligible patients were included, with 363 being men (61.1%) and an average age of 59.2 years at the time of surgery. Forty-seven patients were readmitted within one year, representing an accumulated rate of 7.9%. Among these, 18 (38.3%) readmissions occurred within 30 days and 27 (57.4%) within 90 days. The primary reasons for readmissions included hip dislocation (35.3%), followed by periprosthetic fracture, deep vein thrombosis, delayed incision healing, surgical site infection and others. The multivariate regression model revealed that age (every 10-year increment, OR, 1.39; 95% CI, 1.12-1.88), ARCO stage IV vs. Ⅲ (OR, 3.72; 95% CI, 1.96-7.22), CCI ≥4 vs. <4 (OR = 5.49; 95% CI, 2.16-13.77), admission anemia (OR, 2.72; 95% CI, 1.37-6.83) and surgeon inexperience (OR, 2.74; 95% CI, 1.29-6.73) were significantly associated with unplanned readmission.

Conclusions

These findings provide valuable clinical insights into unplanned readmission after THA for ONFH and may aid in preoperative counselling for patients and enhance perioperative care.

Changes in health-related quality of life in young-old and old-old patients undergoing elective orthopedic surgery: A systematic review

BACKGROUND

There is a significant gap in research exploring changes in postoperative health-related quality of life (HRQoL) among patients aged 65 years and older undergoing hip or knee arthroplasty.

OBJECTIVES

To investigate the variations in HRQoL improvement, as evaluated by patient-reported outcome measures following total hip arthroplasty, total knee arthroplasty, and partial knee arthroplasty between the young-old and old-old adults.

METHODS/DESIGN

We searched six online databases (including MEDLINE, Embase) from their inception dates to May 15, 2023. We included studies using a validated HRQoL assessment tool to evaluate changes in HRQoL in patients aged ≥65 years undergoing hip or knee arthroplasty. These include the EuroQol five-dimension (EQ-5D), Short Form 36 (SF-36) and Short Form 12 (SF-12). The primary outcomes were postoperative HRQoL changes between young-old (65-74 years) and old-old groups (≥75 years). The secondary outcomes included complications, length of stay, and mortality.

RESULTS

The search yielded 12,229 articles; twelve studies (n = 103,613) were included. Studies using EQ-5D found no significant differences between young-old and old-old patients after hip and knee arthroplasty. Analyses of SF-36 and SF-12 scales showed no significant age-related differences in postoperative improvements in physical and mental health. Our review of four studies that included multivariable analyses revealed inconsistent associations between age and EQ-5D. Comparisons between the young-old and old-old age groups in postoperative complications, hospital length of stay, and mortality revealed no associated age-related changes in HRQoL.

CONCLUSIONS

The young-old and old-old patients exhibited comparable improvement in HRQoL following hip or knee arthroplasty. The older patients did not have higher postoperative complications rates, longer hospital length of stay, and increased mortality. While chronological age should be considered when planning hip and knee arthroplasty, greater emphasis should be placed on assessing the comorbidities and functional status of patients.

The Financial Burden of Patient Comorbidities on Total Hip Arthroplasties-A Matched Cohort Analysis of High Comorbidity Burden and Non-High Comorbidity Burden Patients

BACKGROUND

The impact of increased patient comorbidities on the cost-effectiveness of total hip arthroplasty (THAs) is lacking. This study aimed to compare revenue, costs, and short-term (90 days) surgical outcomes between patients who have and do not have a high comorbidity burden (HCB).

METHODS

We retrospectively reviewed 14,949 patients who underwent an elective, unilateral THA between 2012 and 2021. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups, and were further 1:1 propensity matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CMs) of the inpatient episode were compared between groups. Also, 90-day readmissions and revisions were compared between groups. Of the 11,717 patients who had available financial data (n = 1,017 HCB, n = 10,700 non-HCB), 1,914 patients were included in the final matched analyses (957 per group).

RESULTS

Total (P < .001) and direct (P < .001) costs were significantly higher for HCB patients. Comparable revenue between cohorts (P = .083) resulted in a significantly decreased CM in the HCB patient group (P < .001). The HCB patients were less likely to be discharged home (P < .001) and had significantly higher 90-day readmission rates (P = .049).

CONCLUSIONS

Increased THA costs for HCB patients were not matched by increased revenue, resulting in decreased CM. Higher rates of nonhome discharge and readmissions in the HCB population add to the additional financial burden. Adjustments to the current reimbursement models should better account for the increased financial burden of HCB patients undergoing THA and ensure access to care for all patient populations.

LEVEL OF EVIDENCE

III.

A Review of Current Approaches to Pain Management in Knee Osteoarthritis with a Focus on Italian Clinical Landscape

The global cases of knee osteoarthritis (KOA) are projected to increase by 74.9% by 2050. Currently, over half of patients remain dissatisfied with their pain relief. This review addresses unmet needs for moderate-to-severe KOA pain; it offers evidence and insights for improved management. Italian experts from the fields of rheumatology, physical medicine and rehabilitation, orthopedics, primary care, and pain therapy have identified several key issues. They emphasized the need for standardized care protocols to address inconsistencies in patient management across different specialties. Early diagnosis is crucial, as cartilage responds better to early protective and structural therapies. Faster access to physiatrist evaluation and reimbursement for physical, rehabilitative, and pharmacological treatments, including intra-articular (IA) therapy, could reduce access disparities. Concerns surround the adverse effects of oral pharmacological treatments, highlighting the need for safer alternatives. Patient satisfaction with corticosteroids and hyaluronic acid-based IA therapies reduces over time and there is no consensus on the optimal IA therapy protocol. Surgery should be reserved for severe symptoms and radiographic KOA evidence, as chronic pain post-surgery poses significant societal and economic burdens. The experts advocate for a multidisciplinary approach, promoting interaction and collaboration between specialists and general practitioners, to enhance KOA care and treatment consistency in Italy.

Association between diabetes mellitus and total hip arthroplasty outcomes: an observational study using the US National Inpatient Sample

OBJECTIVES

To investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA).

DESIGN

Retrospective cohort study using data from the US National Inpatient Sample (NIS).

SETTING

Study cohort was hospitalisations for primary THA in the USA, identified from the 2016-2020 NIS.

PARTICIPANTS

We identified 2 467 215 adults in the 2016-2020 NIS who underwent primary THA using International Classification of Diseases, 10th Revision codes. Primary THA hospitlizations were analysed as the overall group and also stratified by the underlying primary diagnosis for THA.

OUTCOME MEASURES

Outcome measures of interest were the length of hospital stay>the median, total hospital charges>the median, inpatient mortality, non-routine discharge, need for blood transfusion, prosthetic fracture, prosthetic dislocation and postprocedural infection, including periprosthetic joint infection, deep surgical site infection and postprocedural sepsis.

RESULTS

Among 2 467 215 patients who underwent primary THA, the mean age was 68.7 years, 58.3% were female, 85.7% were white, 61.7% had Medicare payer and 20.4% had a Deyo-Charlson index (adjusted to exclude diabetes mellitus) of 2 or higher. 416 850 (17%) patients had diabetes. In multivariable-adjusted logistic regression in the overall cohort, diabetes was associated with higher odds of a longer hospital stay (adjusted OR (aOR) 1.38; 95% CI 1.35 to 1.41), higher total charges (aOR 1.11; 95% CI 1.09 to 1.13), non-routine discharge (aOR 1.18; 95% CI 1.15 to 1.20), the need for blood transfusion (aOR 1.19; 95% CI 1.15 to 1.23), postprocedural infection (aOR 1.62; 95% CI 1.10 to 2.40) and periprosthetic joint infection (aOR 1.91; 95% CI 1.12 to 3.24). We noted a lack of some associations in the avascular necrosis and inflammatory arthritis cohorts (p>0.05).

CONCLUSION

Diabetes was associated with increased healthcare utilisation, blood transfusion and postprocedural infection risk following primary THA. Optimisation of diabetes with preoperative medical management and/or institution of specific postoperative pathways may improve these outcomes. Larger studies are needed in avascular necrosis and inflammatory arthritis cohorts undergoing primary THA.

Should high-risk patients seek out care from high-volume surgeons?

Aims

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.

Methods

Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.

Results

Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group.

Conclusion

The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.

A modified frailty index predicts complication, readmission, and 30-day mortality following the revision total hip arthroplasty

INTRODUCTION

This study aimed to develop a modified frailty index (MFI) to predict the risks of revision total hip arthroplasty (THA).

METHODS

Data from the American College of Surgeons - National Surgical Quality Improvement Program were analyzed for patients who underwent revision THA from 2015 to 2020. An MFI was composed of the risk factors, including severe obesity (body mass index > 35), osteoporosis, non-independent function status prior to surgery, congestive heart failure within 30 days of surgery, hypoalbuminemia (serum albumin < 3.5), hypertension requiring medication, type 1 or type 2 diabetes, and a history of chronic obstructive pulmonary disease or pneumonia. The patients were assigned based on the MFI scores (MFI0, no risk factor; MFI1, 1-2 risk factors; MFI2, 3-4 risk factors; and MFI3, 5+ risk factors). Confidence intervals were set at 95% with a P value less than or equal to 0.05 considered statistically significant.

RESULTS

A total of 17,868 patients (45% male, 55% female) were included and had an average age of 68.5 ± 11.5 years. Odds of any complication, when compared to MFI0, were 1.4 (95% CI [1.3, 1.6]) times greater for MFI1, 3.2 (95% CI [2.8, 3.6]) times greater for MFI2, and 10.8 (95% CI [5.8, 20.0]) times greater for MFI3 (P < 0.001). Odds of readmission, when compared to MFI0, were 1.4 (95% CI [1.3, 1.7]) times greater for MFI1, 2.5 (95% CI [2.1, 3.0]) times greater for MFI2, and 4.1 (95% CI [2.2, 7.8]) times greater for MFI3 (P < 0.001).

CONCLUSION

Increasing MFI scores correlate with increased odds of complication and readmission in patients who have undergone revision THA. This MFI may be used to predict the risks after revision THA.

Effect of subanesthetic dose of esketamine on postoperative rehabilitation in elderly patients undergoing hip arthroplasty

OBJECTIVE

The majority of individuals with femoral neck fractures opt for total hip replacement to enhance their quality of life. However, this group frequently exhibits perioperative symptoms of pain, anxiety, and sadness, which extends recovery time to some extent. Esketamine, the right-handed monomer of ketamine, is more popular these days due to its sedative, analgesic, and antidepressant properties. There are currently few domestic and international research on the use of esketamine in elderly individuals who have undergone surgery for a femoral neck fracture. In order to further cut the length of the hospital stay and hasten postoperative recovery, this study investigates whether esketamine postoperative analgesia can lessen postoperative pain, anxiety, and depression in older patients having hip replacement.

METHODS

150 patients, ASA physical status I-II, aged ≥ 60 years, no limitation in gender, BMI 18-25 kg/cm², who underwent selective total hip arthroplasty, according to random number table method, esketamine group (group A) and sufentanil group (group B) were randomized, 75 patients in each group. The two groups received general anesthesia method. At the end of the operation, PCIA was connected for analgesia. In group A, esketamine 2.5 mg/kg was mixed with normal saline to 100 ml. In group B, sufentanil 2.5 ug/kg was mixed with normal saline to 100 ml. Record the VAS scores after operation. Record the first ambulation time, ambulation distance and Patient-controlled Analgesia compression times after operation. The incidence of postoperative adverse reactions such as drowsiness, dizziness, nausea and vomiting, multilingual were recorded. ELISA was used to detect IL-6 and CRP in the morning, 24 h and 72 h after operation. The Hospital Anxiety and Depression Scale (HAD) score and Harris score at 3 days, 1 week and 1 month after operation were followed up.

RESULTS

There was no significant difference in VAS score and PCA compression times (P > 0.05), but the incidence of nausea, vomiting and dizziness in group B was higher than that in group A (P < 0.05). Compared with group B, the levels of IL-6 and CRP in group A at 24 h and 72 h after operation were significantly decreased (P < 0.05). Postoperative ambulation time and ambulation distance in group A were better than those in group B (P < 0.05). The HAD score of group A was lower than that of group B at 3 days and 1 week after operation (P < 0.05). However, there was no significant difference between the two groups at 1 month after operation (P > 0.05). The Harris score of group A was higher than that of group B at 3 days, 1 week and 1 month after operation (P < 0.05).

CONCLUSIONS

Esketamine can reduce short-term postoperative anxiety and depression, relieve postoperative pain and stress response, shorten bed rest time after total hip replacement, and accelerate postoperative recovery.

Trends in Revision Total Hip Arthroplasty Cost, Revenue, and Contribution Margin 2011-2021

INTRODUCTION

Revision total hip arthroplasty (rTHA) is a costly procedure and its prevalence has been steadily increasing over time. This study aimed to examine trends in hospital cost, revenue, and contribution margin (CM) in patients undergoing rTHA.

METHODS

We retrospectively reviewed all patients who underwent rTHA from June 2011 to May 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed or Medicaid (GMM), or commercial insurance. Patient demographics, revenue (any payment the hospital received), direct cost (any cost associated with the surgery and hospitalization), total cost (the sum of direct and indirect costs), and CM (The difference between revenue and direct cost) were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analyses were used to determine overall trend significance. Of the 1,613 patients identified, 661 were covered by Medicare, 449 by GMM, and 503 by commercial insurance plans.

RESULTS

Medicare patients exhibited a significant upward trend in revenue (P<0.001), total cost (P=0.004), direct cost (P<0.001), and an overall downward trend in CM (P=0.037), with CM for these patients falling to 72.1% of 2011 values by 2021.

CONCLUSION

In the Medicare population, reimbursement for rTHA has not matched increases in cost, leading to considerable reductions in CM. These trends affect the ability of hospitals to cover indirect costs, threatening access to care for patients who require this necessary procedure. Reimbursement models for rTHA should be reconsidered to ensure the financial feasibility of these procedures for all patient populations.