Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND: Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents. METHODS: A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome. RESULTS: Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%). CONCLUSIONS: These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Outcomes of Unicompartmental Knee Arthroplasty in Patients Receiving Long-Term Anticoagulation Therapy: A Propensity-Matched Cohort Study.

BACKGROUND: Although total knee arthroplasty has been considered the gold-standard treatment for severe osteoarthritis of the knee, unicompartmental knee arthroplasty (UKA) has become an increasingly favorable alternative for single-compartment osteoarthritis of the knee. Few studies have examined potential high-risk populations undergoing this procedure. The purpose of this study was to investigate the outcomes of UKA in patients receiving long-term anticoagulation therapy. METHODS: In this study, a large administrative database was queried to identify patients undergoing UKA between 2009 and 2019, who were then divided into a cohort receiving long-term anticoagulation and a control cohort. Propensity scores were utilized to match these patients. Multivariable logistic regression was utilized to compare 90-day and 2-year complication rates between cohorts. RESULTS: Patients who were on long-term anticoagulation had significantly increased odds of extended length of stay, surgical site infection, wound complication, transfusion, deep vein thrombosis, pulmonary embolism, and readmission at 90-day follow-up. The long-term anticoagulation cohort also experienced significantly higher odds of periprosthetic joint infection and mechanical complications at 2-year follow-up; however, odds of conversion to total knee arthroplasty were not increased. CONCLUSIONS: This study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders.

Early Versus Late Periprosthetic Joint Infection After Total Knee Arthroplasty: Do Patient Differences Exist?

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Little evidence exists comparing those with early versus late PJI. The purpose of the study was to determine comorbidity profile differences between patients developing early and late PJI. METHODS: There were 72,659 patients undergoing primary TKA from 2009 to 2021, who were identified from a commercial claims and encounters database. Subjects diagnosed with PJI were categorized as either 'early' (within 90 days of index procedure) or 'late' (> 2 years after index arthroplasty). Non-infected patients within these periods served as control groups following 4:1 propensity score matching on other extraneous variables. Logistic regression analyses were performed comparing comorbidities between groups. RESULTS: Patients were significantly younger in the late compared to the early infection group (58.1 versus 62.4 years, P < .001). When compared to those with early PJI, patients who had chronic kidney disease (13.3 versus 4.1%; OR [odds ratio] 5.17, P = .002), malignancy (20.4 versus 10.5%; OR 2.53, P = .009), uncomplicated diabetes (40.8 versus 30.6%; OR 2.00, P = .01), rheumatoid arthritis (9.2 versus 3.3%; OR 2.66, P = .046), and hypertension (88.8 versus 81.6%; OR 2.17, P = .04), were all significant predictors of developing a late PJI. CONCLUSIONS: When compared to patients diagnosed with early PJI following primary TKA, the presence of chronic kidney disease, malignancy, uncomplicated diabetes, rheumatoid arthritis, and hypertension, were independent risk factors for the development of late PJI. Younger patients who have these comorbidities may be targets for preoperative optimization interventions that minimize the risk of PJI.

Complications Rates Among Revision Total Knee Arthroplasty Patients Diagnosed With COVID-19 Postoperatively.

BACKGROUND: The COVID-19 pandemic introduced a new set of challenges for the arthroplasty community, including the management of patients diagnosed with COVID-19 following revision total knee arthroplasty (rTKA) and its potential impact on postoperative recovery. This study sought to characterize the risks of postoperative COVID-19 infection among rTKA patients. METHODS: A large national database was utilized to query 8,022 total patients who underwent rTKA between 2018 and 2021, of which 60 had a COVID diagnosis within 90 days after surgery (rTKA/COVID positive). These patients were 1:10 propensity-score matched to 600 rTKA patients who did not have a 90-day postoperative COVID diagnosis (rTKA/COVID negative) and 600 COVID positive patients who did not undergo rTKA. Controlling for potential confounders, multivariate logistic regressions were utilized to compare 90-day postoperative complications between groups. RESULTS: Compared to rTKA/COVID negativepatients, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (odds ratio [OR] = 6.1, P < .001), pulmonary embolism (PE) (OR = 32.4, P < .001), deep venous thrombosis (DVT) (OR = 32.4, P < .001), and 90-day readmissions (OR = 2.1, P = .02). Similarly, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (OR = 4.3, P = .001), PE (OR = 36.8, P < .001), and DVT (OR = 36.8, P < .001) compared to COVID positive patients who did not undergo rTKA. CONCLUSIONS: Revision total knee arthroplasty patients diagnosed with COVID-19 postoperatively had increased rates of thromboembolic events, pneumoniae, and 90-day readmissions. Risk mitigation efforts would suggest extending the prophylactic anticoagulation period for rTKA patients diagnosed with postoperative COVID-19.

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty.

BACKGROUND: Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively. METHODS: We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks. RESULTS: All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003). CONCLUSIONS: This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS: In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS: Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS: All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE: III, Retrospective review.

Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR. METHODS: Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared. RESULTS: The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006). CONCLUSION: ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study.

BACKGROUND: It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort. METHODS: All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions. RESULTS: The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort. CONCLUSION: Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study.

BACKGROUND: As the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes. METHODS: In this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression. RESULTS: In total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001). CONCLUSION: THA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient.

BACKGROUND: Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications. METHODS: This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses. RESULTS: Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001). CONCLUSION: Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty.

BACKGROUND: Depression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA. METHODS: This is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications. RESULTS: In total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001). CONCLUSIONS: NOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.

Preoperative Analgesia, Complications, and Resource Utilization After Total Hip Arthroplasty: Tramadol Is Associated With Less Risk Than Other Preoperative Opioid Medications.

BACKGROUND: Preoperative opioid use is known to be detrimental to outcomes after total hip arthroplasty (THA). This is concerning as multiple societies recommend tramadol for the management of arthritis. The purpose of this study was to determine if tramadol is associated with postoperative complications, increased resource utilization, and revision when compared with patients receiving nontramadol opioids (NTOs) and those who are opioid naive (ON). METHODS: This is a retrospective cohort study using the Truven MarketScan databases (Truven Health, Ann Arbor, MI). Adult patients undergoing primary THA were identified and divided into 4 cohorts based on preoperative opioid medications (ie, ON, tramadol-only [TO], or NTOs; ±tramadol). Demographics, comorbidities, and 90-day complications were collected and compared between cohorts. Revision rates were compared at 3 years. Univariate and multivariate analyses were performed. Finally, preoperative prescription patterns were trended during the study period. RESULTS: About 198,357 patients, including 18,694 TO and 106,768 ON, were identified. Compared with ON, TO patients had similar rates of complications and revision surgery (P > .05) but had slightly higher emergency department visits (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 1.01-1.12; P = .027), readmissions (OR, 1.16; 95% CI, 1.09-1.22; P < .001), and nonhome discharges (OR, 1.07; 95% CI, 1.02-1.12; P = .010). TO patients had significantly lower odds of incurring most examined complications, including revision surgery, when compared with NTO (P < .05). From 2009 to 2018, the proportion of patients prescribed preoperative opioids decreased. CONCLUSION: Preoperative TO is associated with less postoperative risk than NTO use and is similar to opioid naivety. Fortunately, the number of patients receiving preoperative NTOs appears to be decreasing. Our results support tramadol as an appropriate pre-THA analgesic.

Anterior Revision Hip Arthroplasty is Associated With Higher Wound Complications but Fewer Dislocations Compared to Posterior Revision Hip Surgery.

BACKGROUND: Wound complication after primary direct anterior (DAA) hip arthroplasty has been reported in the literature but there has been no comparison regarding revision anterior vs revision posterior (PA) hip arthroplasty. The authors hypothesize that anterior approach revision surgery may have increased wound complications compared with posterior hip revisions and also report on secondary outcome metrics. METHODS: Ninety-nine DAA and 191 PA revisions were included for analysis. Preoperative demographic characteristics, indication for revision, operative details, type of revision performed, components utilized, and postoperative complications were compared between DAA and PA groups including multivariate analysis. RESULTS: The DAA cohort demonstrated an increased risk of superficial wound complications (7.1% vs 0.5%, P = .003) and a decreased dislocation rate (2.0% vs 13.1%, P = .002). There was a trend toward increased overall complications in the PA group (OR 1.71, P = .078). CONCLUSION: Revision DAA THA is associated with an increased risk of superficial wound complications, but may impart a decreased dislocation rate.

The Effectiveness of Closed-Incision Negative-Pressure Therapy Versus Silver-Impregnated Dressings in Mitigating Surgical Site Complications in High-Risk Patients After Revision Knee Arthroplasty: The PROMISES Randomized Controlled Trial.

BACKGROUND: Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up. METHODS: This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs. RESULTS: Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05). CONCLUSION: ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses.

Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database.

BACKGROUND: The incidence of revision THA continues to increase and there is a need to identify risk factors contributing to postoperative complications. Anesthesia type has been shown to be associated with complication rates in patients who undergo primary THA, but it is not clear whether the same is true among patients undergoing revision THA. QUESTIONS/PURPOSES: (1) After controlling for confounding variables, in the setting of a large-database analysis, is spinal anesthesia associated with a lower risk of death, readmission, reoperation, postoperative transfusion, thromboembolic events, surgical site infection (SSI), and re-intubation among patients undergoing revision THA? METHODS: The American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing aseptic, revision THA with either spinal or general anesthesia. Coarsened exact matching was used to match patients based on several baseline characteristics, including age, sex, body mass index, surgery type (Current Procedural Terminology code), and the modified Frailty Index score. Coarsened exact matching is a statistical method of exact matching that matches on chosen characteristics, in which continuous variables may be temporarily coarsened (such as, into discrete categorical variables) to facilitate matching. This method is an alternate to and requires less estimation than traditional propensity score matching. Then, using a model controlling for baseline patient characteristics and operative time, we performed multivariate logistic and linear regression analyses of matched cohorts to examine differences in mortality, readmission, reoperation, thromboembolic events, transfusion, SSI, and re-intubation. RESULTS: After statistical matching and controlling for baseline demographic variables, surgery type (one- or two-component revision), surgical time and modified Frailty Index we found that patients receiving general anesthesia had higher odds of mortality (OR 3.72 [95% CI 1.31 to 10.50]; p = 0.013), readmission (OR 1.49 [95% CI 1.24 to 1.80]; p < 0.001), reoperation (OR 1.40 [95% CI 1.13 to 1.73]; p = 0.002), thromboembolic events (OR 2.57 [95% CI 1.37 to 4.84]; p = 0.003), SSI (OR 1.32 [95% CI 1.01 to 1.72]; p = 0.046), postoperative transfusion (OR 1.57 [95%CI 1.39 to 1.78]; p < 0.001) and unplanned intubation or failure to wean off intubation (OR 5.95 [95% CI 1.43 to 24.72]; p = 0.014). CONCLUSIONS: In patients undergoing revision THA, spinal anesthesia is associated with a decreased risk of several complications. The current investigation suggests that, when practical (such as when long surgical times or changes to the surgical plan are not anticipated), spinal anesthesia should be considered for use during revision THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030.

BACKGROUND: As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA. METHODS: The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age. RESULTS: In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA. CONCLUSION: The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends. LEVEL OF EVIDENCE: IV.

Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty.

BACKGROUND: The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient. METHODS: This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts. RESULTS: 105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001). CONCLUSIONS: Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.

Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients. METHODS: We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence. RESULTS: Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group. CONCLUSION: Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.

Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty.

BACKGROUND: The incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship. METHODS: This is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts. RESULTS: A total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001). CONCLUSION: Depression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.