The Association Between Mental Health, Substance Use Disorder, and Outcomes After Total Joint Arthroplasty.

BACKGROUND: Prior studies suggest that distressed patients or those who have poor mental health have inferior postoperative outcomes when compared to nondistressed patients. However, these studies typically do not account for substance use or other comorbidities often found in this population, which can independently contribute to postoperative complications. This study sought to control for these factors and assess if a diagnosis of a mental health condition is directly associated with worse outcomes after total joint arthroplasty. METHODS: A retrospective chart review was performed for 3,182 patients who underwent a total hip arthroplasty and 4,430 patients who underwent a total knee arthroplasty. Diagnosis of the mental health disorders included depression, anxiety disorder, adjustment disorder, bipolar disorder, trauma, stressor-related disorder, and schizophrenia or schizoaffective disorder. Multivariable analyses were performed to control for alcohol use, drug use, tobacco use, body mass index, and a comorbidity index. RESULTS: When controlling for body mass index and Charlson comorbidity index, no statistically significant associations were found between a diagnosis of any mental health condition or a specific diagnosis of depression or anxiety, and 90-day readmission, reoperation, or 1 year mortality for patients undergoing total knee arthroplasty or total hip arthroplasty. CONCLUSIONS: When accounting for confounding factors, there does not appear to be a direct association between diagnosis of any of the psychiatric conditions we studied and outcomes after primary total joint arthroplasty. While prior studies suggest addressing the mental health condition may improve outcomes, this study suggests that preoperative medical optimization and potentially addressing substance use may be more effective strategies.

Risk Factors for Trochanteric Bursitis Following Total Hip Arthroplasty: A Radiographic Analysis.

BACKGROUND: Trochanteric bursitis (TB) is a prevalent complication following total hip arthroplasty (THA), with increased offset hypothesized as a potential risk factor. This study investigated potential TB predictors in THA patients, including radiographic measurements of offset and leg length, comorbidities, and patient characteristics. METHODS: In this retrospective cohort study, all THA patients from a single academic tertiary care center between 2005 and 2021 were reviewed. Exclusion criteria included less than one-year follow-up, osteonecrosis, or fracture. Manual radiographic measurements of offset (acetabular, femoral, and total) and leg length from preoperative and postoperative AP (antero-posterior) pelvis X-rays were taken, with scaling using femoral cortical diameter. Univariable and multivariable Cox proportional hazard models were employed to estimate TB risk. RESULTS: Of 1,094 patients, 103 (9.4%) developed trochanteric bursitis, with a median (Q1, Q3) time to presentation of 41.8 weeks (25.5, 66.9). In univariable models, only sex was associated with increased TB risk, with women exhibiting a 1.79 times increased risk (HR [hazard ratio]: 1.79 (1.16, 2.76), P = 0.009). Changes in acetabular offset, femoral offset, total offset, and leg length between preoperative and postoperative radiographs were not associated with an increased risk of developing TB in the univariate or multivariate models. Furthermore, various offset thresholds were evaluated, with no amount of increased offset showing increased TB risk. CONCLUSION: This study found no relationship between femoral, acetabular, or total offset and trochanteric bursitis following THA. These findings suggest that surgeons may consider adding offset for increased prosthetic stability in high-risk cases. However, given that this is a retrospective study, the authors are not advocating for the routine use of increased offset. The study identified women as a risk factor with a 1.79 times higher TB risk, highlighting the importance of counseling women patients on this heightened risk.

Morbidity and Mortality Following Total Hip and Knee Arthroplasty With Spinal Versus General Anesthesia: A Retrospective Analysis.

BACKGROUND: The optimal anesthetic mode in total joint arthroplasty (TJA) has yet to be clearly identified. Patients undergoing TJA may recieve spinal anesthesia (SA) or general anesthesia (GA). While arthroplasty literature indicates differences in postoperative morbidity, hip fracture literature does not show clear superiority of SA or GA. The purpose of this study was to further investigate this relationship and determine if there is a significant difference in morbidity and mortality between GA and SA in patients undergoing primary total joint arthroplasty. METHODS: Patients undergoing primary THA or TKA from February 2007 to February 2021 were retrospectively reviewed, creating four cohorts: THA/GA (n = 1,266), THA/SA (n = 1,084), TKA/GA (n = 882), and THA/SA (n = 2,067). Readmission within 90 days, mortality within 365 days, and thromboembolic events within 30 days postoperatively were compared using logistic regression, controlling for age, body mass index, and Charlson Comorbidity Index. RESULTS: The odds of experiencing a deep venous thrombosis within 30 days postoperatively were elevated in the analysis of both the THA/GA (odds ratio (OR) = 3.1; 95% confidence interval (CI): 1.5 to 7.0; P = .004) and the TKA/GA (OR = 1.9; 95% CI: 1.2 to 3.0; P = .005) groups. Similarly, the risk of pulmonary embolism as higher in the THA/GA cohort (OR = 3.9; 95% CI: 1.2 to 17.3; P = .04). There were also higher odds of mortality within 365 days postoperatively in THA/GA patients (OR = 4.3; 95% CI: 1.7 to 13.0; P = .004). No other differences existed among TKA patients. CONCLUSIONS: Based upon these data, both SA and GA are reasonable options for primary TKA with similar risk profiles. However, GA may be associated with higher rates of deep venous thrombosis in TJA and pulmonary embolism in THA. General anesthesia (GA) was also loosely associated with increased mortality within 1 year of THA, but this result should be considered with caution.

Prevention Techniques Have Had Minimal Impact on the Population Rate of Prosthetic Joint Infection for Primary Total Hip and Knee Arthroplasty: A National Database Study.

BACKGROUND: Several studies over the years have offered modalities that may greatly decrease the rate of periprosthetic joint infection when implemented. As a result, one would expect a drastic decrease in infection rate among the implementing population with its widespread use. The purpose of this study was to assess whether there exists a decrease in infection rate over time, after accounting for available confounding variables, within a large national database. METHODS: A large national database from 2005 to 2019 was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). In total, 221,416 THAs and 354,049 TKAs were performed over the study period. Differences in 30-day infection rate were assessed with time and available preoperative risk factors using multinominal logistic regressions. RESULTS: Rate of infection overall trended downward for both THA and TKA. After accounting for confounding variables, odds of THA infection marginally decreased over time (odds ratio 0.968 [0.952-0.985], P < .0001), while the odds of a TKA infection marginally increased with time (odds ratio 1.037 [1.020-1.054], P < .0001). CONCLUSION: Individual peer-reviewed publications have presented infection control modalities demonstrating dramatic decreases in infection rate while analysis at a population level shows almost no changes in infection rate over a 15-year time period. This study supports continued investigation for influential modalities in preventing periprosthetic joint infection and care in patient selection for primary hip and knee arthroplasty.

Artificial Intelligence Autonomously Measures Cup Orientation, Corrects for Pelvis Orientation, and Identifies Retroversion From Antero-Posterior Pelvis Radiographs.

BACKGROUND: Measuring cup orientation is time consuming and inaccurate, but orientation influences the risk of impingement and dislocation following total hip arthroplasty (THA). This study designed an artificial intelligence (AI) program to autonomously determine cup orientation, correct for pelvis orientation, and identify cup retroversion from an antero-posterior pelvic radiographs. METHODS: There were 2,945 patients between 2012 and 2019 identified to have 504 computed tomographic (CT) scans of their THA. A 3-dimensional (3D) reconstruction was performed on all CTs, where cup orientation was measured relative to the anterior pelvic plane. Patients were randomly allocated to training (4,000 x-rays), validation (511 x-rays), and testing (690 x-rays) groups. Data augmentation was applied to the training set (n = 4,000,000) to increase model robustness. Statistical analyses were performed only on the test group in their accuracy with CT measurements. RESULTS: AI predictions averaged 0.22 ± 0.03 seconds to run on a given radiograph. Pearson correlation coefficient was 0.976 and 0.984 for AI measurements with CT, while hand measurements were 0.650 and 0.687 for anteversion and inclination, respectively. The AI measurements more closely represented CT scans when compared to hand measurements (P < .001). Measurements averaged 0.04 ± 2.21°, 0.14 ± 1.66°, -0.31 ± 8.35°, and 6.48° ± 7.43° from CT measurements for AI anteversion, AI inclination, hand anteversion, and hand inclination, respectively. AI predictions identified 17 radiographs as retroverted with 100.0% accuracy (total retroverted, n = 45). CONCLUSION: The AI algorithms may correct for pelvis orientation when measuring cup orientation on radiographs, outperform hand measurements, and may be implemented in a timely fashion. This is the first method to identify a retroverted cup from a single AP radiograph.

Impact of Perioperative Urinary Tract Infection on Surgical Site Infection in Patients Undergoing Primary Hip and Knee Arthroplasty.

BACKGROUND: The literature lacks clear consensus regarding the association between postoperative urinary tract infection (UTI) and surgical site infection (SSI). Additionally, in contrast to preoperative asymptomatic bacteriuria, SSI risk in patients with preoperative UTI has been incompletely studied. Therefore, our goal was to determine the effect of perioperative UTI on SSI in patients undergoing primary hip and knee arthroplasty. METHODS: Using the National Surgical Quality Improvement Program database, all patients undergoing primary hip and knee arthroplasty were identified. Univariate and multivariate regressions, as well as propensity matching, were used to determine the independent risk of preoperative and postoperative UTI on SSI, reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Postoperative UTI significantly increased the risk for superficial wound infection (OR 2.147, 95% CI 1.622-2.842), deep periprosthetic joint infection (PJI) (OR 2.288, 95% CI 1.579-3.316), and all SSIs (superficial and deep) (OR 2.193, 95% CI 1.741-2.763) (all P < .001). Preoperative UTI was not associated with a significantly increased risk of superficial infection (P = .636), PJI (P = .330), or all SSIs (P = .284). Further analysis of UTI present at the time of surgery using propensity matching showed no increased risk of superficial infection (P = 1.000), PJI (P = .624), or SSI (P = .546). CONCLUSION: Postoperative UTI was associated with SSI, reinforcing the need to minimize factors which predispose patients to the risk of UTI after surgery. The lack of association between preoperative UTI and SSI suggests that hip and knee arthroplasty can proceed without delay, although initiating antibiotic treatment is prudent and future prospective investigations are warranted.

Ankle fusion in patients with chronic hepatitis C.

BACKGROUND: It appears that both the incidence and survival of patients infected with hepatitis C have recently demonstrated a significant increase. The goal of this investigation was to determine the associated perioperative risks associated with ankle arthrodesis in this growing population. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases identified patients with chronic hepatitis C infection who underwent ankle arthrodesis between January 2009 and December 2013. International Classification of Diseases, Ninth Revision, codes were used to define the primary composite outcome of death or postoperative complication. Logistic models with frequency weights were used to compare propensity matched groups. RESULTS: 7339 patients met inclusion criteria. Of these, 157 patients had a history of chronic Hepatitis C infection. After performing a propensity score match, the final analytic cohort was 157 in the Hepatitis C group and 386 in the non-Hepatitis C group. There was no statistically significant differences in complications between patients with chronic Hepatitis C undergoing ankle fusion and those without Hepatitis C at any post-operative time point (inpatient, 30 days, or 90 days). DISCUSSION: Patients with chronic hepatitis C infection undergoing ankle arthrodesis are not at an elevated risk of inpatient, thirty, and ninety day postoperative complications compared to patients without chronic HCV infections. Patients with chronic hepatitis C did not have an increased risk of surgical site infection or mortality at any time point. LEVEL OF EVIDENCE: Prognostic Level III.

Arthroscopic versus open irrigation and debridement in native knee septic arthritis: A retrospective review.

Introduction: Native knee septic arthritis is a rare condition with a potential for high morbidity if not promptly treated. Treatment involves surgical decompression of the affected joint along with systemic antibiotic therapy. The purpose of this study is to compare arthroscopic versus open irrigation and debridement for treatment of native knee septic arthritis. Methods: A retrospective review was conducted at a single academic institution of all patients treated for native knee septic arthritis from January 2007 until August 2018 utilizing ICD and CPT codes. Patient demographics, type of surgical procedure, need for reoperation, laboratory values, length of stay, and comorbidities were compared. Results: A cohort of sixty-six patients who underwent 85 surgeries were included. Among these surgeries, 52 (61%) were arthroscopic while 33 (39%) were open arthrotomies, and 21% required more than one operation. While not statistically significant, the odds of reoperation was higher for those that underwent arthroscopic compared to open irrigation and debridement on univariable (OR = 4.05, p = .08) and multivariable analysis (OR = 4.39, p = .10). Additionally, patients were more likely to require a longer hospital stay if they initially underwent arthroscopic rather than open debridement (RR = 1.31, p = .02). Conclusion: Native knee septic arthritis can be treated with a single surgery in the majority of cases. In our sample, there was an increased odds of reoperation in those treated arthroscopically compared to open, though this finding was not statistically significant. We found longer length of stay for patients undergoing arthroscopic rather than open irrigation and debridement - even after controlling for multiple operations, culture status, sex, age, and comorbidities.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty.

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Unicompartmental knee arthroplasty and revision total knee arthroplasty have a lower risk of venous thromboembolism disease at 30 days than primary total knee arthroplasty.

BACKGROUND: While multiple studies have demonstrated a lower venous thromboembolism disease (VTED) risk for unicompartmental knee arthroplasty (UKA) compared to primary total knee arthroplasty (TKA), recent reports have shown that revision TKA also had a lower VTED risk compared to primary TKA, an unexpected finding because of its theoretical increased risk. Given the paucity of up-to-date comparative studies, our goal was to perform a high-powered VTED risk comparison study of UKA and revision TKA to primary TKA using recent data. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried between 2011 and 2018, and we identified 213,234 patients for inclusion: 191,810 primary TKA, 9294 UKA, and 12,130 revision TKA. Demographics, medical comorbidities, and possible VTE risk factors were collected. Thirty-day outcomes, including deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause VTED were compared between knee arthroplasty types. RESULTS: On multivariate analysis, UKA was significantly associated with lower rates of DVT [OR 0.44 (0.31-0.61); P < 0.001], PE [OR 0.42 (0.28-0.65); P < 0.001], and all-cause VTED [OR 0.42 (0.32-0.55); P < 0.001] when compared to primary TKA. Revision TKA was significantly associated with lower rates of PE [OR 0.62 (0.47-0.83); P = 0.002], and all-cause VTED [OR 0.82 (0.70-0.98); P = 0.029] when compared to primary TKA. CONCLUSIONS: Utilizing recent data from a nationwide patient cohort and controlling for confounding variables, our results showed that both revision TKA and UKA had a lower risk of VTED compared to primary TKA, corroborating the results of recent investigations. Additional prospective investigations are needed to explain this unexpected result.

The Impact of Antibiotic-Loaded Bone Cement on Antibiotic Resistance in Periprosthetic Knee Infections.

BACKGROUD: Antibiotic-loaded bone cement (ALBC) is commonly used in total knee arthroplasty (TKA), especially among high-risk patients. While previous studies have reported on the efficacy of ALBC in reducing the rate of periprosthetic joint infection (PJI), its impact on antibiotic resistance has not been determined. The purpose of this study was to investigate antibiotic resistance among organisms causing PJIs after TKA in which ALBC was utilized. METHODS: A retrospective review from December 1998 through December 2017 identified 36 PJIs that met inclusion criteria. Patients with culture-negative infection and unknown cement type were excluded. Patient characteristics, infecting organism, and antibiotic susceptibilities were recorded. ABLC included an aminoglycoside in all cases. RESULTS: There was no difference in the type of PJI between the 2 groups. Staphylococcus species was the most commonly isolated, with 9 of 16 cases (56.3%) using non-ALBC and 14 of 20 (65.0%) cases using ALBC. Of those infected with Staphylococcus, there was no significant difference in antibiotic susceptibilities between groups. Overall, there were only 3 cases where the infecting organism was aminoglycoside resistant (standard cement, 1; ALBC, 2). CONCLUSIONS: These results suggest that the use of ALBC does not increase the risk of antibiotic resistance or affect the pattern of infection, even as the use of ALBC continues to increase, particularly among high-risk patients.

Comparison of perioperative outcomes and cost of spinal fusion for cervical trauma: weekday versus weekend admissions.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To characterize the impact of the admission day (weekday vs. weekend) on the length of stay, costs, complications, and mortality in patients undergoing cervical spine surgery for spinal trauma. SUMMARY OF BACKGROUND DATA: The effect of the admission day on the hospital outcomes for patients undergoing anterior cervical fusion (ACF), posterior cervical fusion (PCF), or anterior and posterior cervical fusion (APCF) to manage cervical spine trauma remains unknown. METHODS: The Nationwide Inpatient Sample was queried from 2002 to 2011. Patients undergoing an ACF, PCF, or APCF for the treatment of cervical spine trauma were identified. Patients were separated into cohorts based on the day of admission (weekday vs. weekend). Patient demographics, comorbidities, admission status, length of stay, costs, mortality, and outcomes were assessed. A value of P ≤ 0.001 denoted statistical significance due to the large sample size. RESULTS: A total of 34,122 patients underwent cervical fusion for cervical spine trauma between 2002 and 2011. Weekend admits accounted for 11.5% (n = 3126), 19.9% (n = 1048), and 17.2% (n = 301) of the ACF, PCF, and APCF procedures, respectively. On average, the weekend admits in all surgical approaches were younger, had a predilection toward more males, and demonstrated fewer comorbidities than the weekday cohort. ACF-treated weekend admits were hospitalized 4.4 days longer (P = 0.00001) and incurred $10,045 more in total hospital costs than the ACF-treated weekday admits (P = 0.0003). PCF-treated weekend admits were hospitalized 2.6 days longer (P = 0.0003) and incurred $10,227 more in total hospital costs (P = 0.0005). Finally, the APCF-treated weekend admits were hospitalized 4.2 days longer (P = 0.0004) and incurred $11,301 more in total hospital costs (P = 0.0001). The mortality rates were not significantly different among the admission-day cohorts. The ACF-treated weekend cohort demonstrated significantly greater incidences of postoperative infection (P = 0.0003), cardiac complications (P = 0.0004), and urinary tract infection (P = 0.0001) than their weekday admit counterparts. CONCLUSION: The weekend cohorts in all surgical approaches incurred a greater length of stay and total hospital costs than their weekday counterparts. The ACF-treated weekend cohort demonstrated significantly greater incidences of postoperative infection, cardiac complications, and urinary tract infection. There were no significant differences in mortality based on the admission day for any surgical approach. Further research is warranted to further evaluate hospital utilization, costs, and patient outcomes based on the admission day.