Racial disparities in post-operative complications and discharge destination following total joints arthroplasty: a national database study.

INTRODUCTION: The objective of this study was to explore race-based differences in 30-day complication rates following total joint arthroplasty (TJA) using a large national database. METHODS: Patients undergoing primary, elective THA and TKA between 2012 and 2018 were retrospectively reviewed using the ACS-NSQIP. We compared Black and Hispanic patients with non-Hispanic White patients using multivariate statistical models adjusting for demographic, operative, and medical characteristics. RESULTS: A total of 324,795 and 200,023 patients undergoing THA and TKA, respectively, were identified. After THA, compared to White patients, Black and Hispanic patients were more likely to be diagnosed with VTE (p < 0.001), receive a blood transfusion (p < 0.001), and to be discharged to an inpatient facility (p < 0.001). After TKA, compared to White patients, Black and Hispanic patients were more likely to experience a major complication (p < 0.001 and p = 0.008, respectively), be diagnosed with VTE (p < 0.001), and be discharged to a facility (p < 0.001). CONCLUSIONS: Our findings indicate higher rates of VTE, blood transfusions, and discharge to an inpatient facility for Black and Hispanic patients when compared to White patients following TJA, though we are unable to comment on the etiology of these disparities. These results may contribute to a growing divide with respect to outcomes and access to TJA for these at-risk patient populations.

Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study.

BACKGROUND: Distal femur fractures (DFFx) are highly morbid injuries with a complication rate comparable to hip fractures. Rising rates of total knee arthroplasty (TKA) have led to increasing rates of periprosthetic DFFx (pDFFx). We sought to determine how pDFFx complication rates differed from native DFFx (nDFFx). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who sustained pDFFx or nDFFx between 2012 and 2018. Patients were further stratified by operative treatment: open reduction internal fixation (ORIF) or distal femur replacement (DFR). Multivariate logistic regression was used to compare 30-day complication rates between pDFFx versus nDFFx and, among pDFFx patients, ORIF versus DFR or revision TKA (rTKA). RESULTS: 563 patients with pDFFx and 2259 patients with nDFFx were identified between 2012 and 2018. pDFFx patients had significantly lower rates of ORIF than nDFFx patients (36.4 vs 95.4%, p < 0.001). On multivariate analysis, pDFFx were associated with a higher rate of surgical site complications (OR 2.48, p = 0.009) compared to nDFFx. There were no differences in mortality, reoperations, major complications, rate of blood transfusion, venous thromboembolism and disposition. In patients with pDFFx, patients undergoing DFR/rTKA were more likely to be discharged home versus a rehab facility, compared to those undergoing ORIF (OR 2.62, p < 0.001). CONCLUSIONS: In this first large registry study comparing pDFFx and nDFFx, we find similar outcomes between these groups in the first 30 days after surgery. Patients with pDFFx did have higher rates of surgical site complications, including infection and dehiscence. In pDFFx patients, those undergoing DFR were more likely to return home post-operatively.

A clinical decision tool for septic arthritis in children based on epidemiologic data of atraumatic swollen painful joints in South Africa.

BACKGROUND: In settings with limited access to specialist services, differentiating septic arthritis-a surgical emergency-from non-infectious atraumatic arthropathy in paediatric patients is challenging, especially in a setting with a high burden of tuberculosis (TB). We aimed to investigate the aetiologies of swollen, painful joints in an urban setting in South Africa and determine how clinical and laboratory findings varied with diagnosis. PATIENTS AND METHODS: A retrospective review of patients aged 12 or younger presenting to a paediatric hospital in Cape Town, South Africa, with atraumatic swollen, painful joints was conducted over a two year period from 2013 to 2015. Children were excluded if they did not have tissue culture or analysis conducted at our facility. Aetiology was classified as non-infectious, TB septic arthritis, or pyogenic arthritis from other bacterial causes. RESULTS: One hundred and four children met inclusion criteria. Arthritis was classified as non-infectious in 43 (41%), TB in 15 (14%), and pyogenic in 40 (38%), with six (6%) patients never receiving a final diagnosis. Mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WCC) were all significantly higher in pyogenic infectious arthritis compared with TB and non-infectious arthritis. There were no significant differences in these parameters between non-infectious and TB arthritis. Using cut-point analysis, thresholds were identified predictive of the presence of pyogenic arthritis versus TB or non-infectious arthritis; these included the presence of fever, CRP > 50 mg/L, ESR > 65 mm/h and WCC > 12x109/L. The absence of all of these criteria resulted in a negative predictive value of 100% for pyogenic infection; the presence of three to four criteria resulted in a positive predictive value of 71%. CONCLUSIONS: Despite insignificant differences in their clinical presentation compared with non-infectious arthidities, 15% of children were diagnosed with tissue-confirmed TB infection. Predictive values of clinical criteria are reduced in our population due to elevated levels of inflammatory markers in all patients. Synovial biopsy to rule out TB is recommended in all patients in a high-burden setting given clinical similarity to non-infectious aetiologies.

Revision Total Hip Arthroplasty in Solid Organ Transplant Patients: A Propensity Score-Matched Cohort Study for Aseptic and Infected Revisions.

BACKGROUND: Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total hip arthroplasty (THA) are at an increased risk of postoperative complications. The purpose of this study is to use a large, national database to investigate revision THA (rTHA) outcomes in SOT patients. METHODS: Nationwide Readmissions Database (NRD) from 2010-2018 was used, and ICD-9 and ICD-10 codes were used to identify all patients who underwent rTHA, including those with history of SOT. Propensity score matching (PSM) was used to analyze rTHA outcomes in SOT patients comparted to matched controls. Separate analysis performed for patients undergoing rTHA for prosthetic joint infection (PJI) vs other causes. RESULTS: A total of 414,756 rTHA, with 1837 of those being performed in SOT patients, were identified. Of these, 65,961 and 276 were performed for PJI in non-SOT and SOT patients, respectively. For non-PJI patients, SOT patients had higher 90-day all-cause readmission rates (24.0% vs 19.4%, P = .03) but lower rate for readmission related to rTHA (6.0% vs 9.2%, P = .03), but no difference readmission for specific rTHA complications, mortality (0.6% vs 1.3%, P = .20), or revision rTHA. Of PJI patients, SOT patients had no difference in overall 90-day readmission (38.6 vs 31.3%, P = .280), readmission for specific rTHA complications, re-revision, or mortality (4.7% vs 6.0%, P = .63). CONCLUSIONS: SOT patients undergoing rTHA for aseptic reasons are higher risk of overall readmission but lower risk of readmission related to rTHA than appropriately matched controls. SOT PJI patients undergoing had similar rates of readmission, mortality, and revision surgery compared to matched non-SOT PJI patients.

Rates and timing of short-term complications following operative treatment of tibial shaft fractures.

INTRODUCTION: Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications. RESULTS: A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications. CONCLUSIONS: Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.

Instability Is the Most Common Indication for Revision Hip Arthroplasty in the United States: National Trends From 2012 to 2018.

BACKGROUND: As primary total hip arthroplasty volume continues to increase, so will the number of revision total hip arthroplasty (rTHA) procedures. These complex cases represent a significant clinical and financial burden to the health-care system. METHODS: This was a retrospective review using the National Inpatient Sample. International Classification of Diseases, 9th and 10th revision codes were used to identify patients who underwent rTHA and create cohorts based on rTHA indications from 2012 to 2018. National and regional trends for length of stay (LOS), cost, and discharge location were evaluated. RESULTS: A total of 292,250 rTHA procedures were identified. The annual number of rTHA procedures increased by 28.1% from 2012 to 2018 (37,325 to 47,810). The top 3 indications for rTHA were instability (20.4%), aseptic loosening (17.8%), and infection (11.1%). Over the study period, the proportion of patients discharged to skilled nursing facility decreased from 44.2% to 38% (P < .001). Hospital LOS decreased on average from 4.8 to 4.4 days (P < .001). Infections had the highest average LOS (7.3 days) followed by periprosthetic fractures (6.5 days). Hospital costs decreased over the study period, from $25,794 to $24,555 (P < .001). The proportion of rTHA cases performed at urban academic centers increased (58.0% to 75.3%, P < .001) while the proportion performed at urban nonacademic centers decreased (35.5% to 19.4%, P < .001). CONCLUSION: Instability was the most common indication for rTHA between 2012 and 2018. The proportion of rTHA performed in urban academic centers has increased substantially, away from urban nonacademic centers. While cost and LOS have decreased, significant geographic variability exists.