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Tuloup V, Doumit C, Lartigue MF, Le Nail LR, Lacasse M, Lemaignen A. Cirrhotic patients with bone and joint infections: A 10-year cohort study from a reference center. Infect Dis Now 2025; 55:105099. [PMID: 40403876 DOI: 10.1016/j.idnow.2025.105099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2024] [Revised: 05/14/2025] [Accepted: 05/19/2025] [Indexed: 05/24/2025]
Abstract
INTRODUCTION Bone and joint infections (BJI) require long-term and frequently high-dose antimicrobial treatment, often with heightened risk of drug-drug or drug-disease interactions. However, in some cases, notably regarding cirrhotic patients, these infections have yet to be adequately described. Cirrhosis is a major cause of end-stage chronic liver disease, entailing massive disorders in hepatic metabolism and a high rate of infections and comorbidities. We aimed to characterize the cirrhosis - BJI population treated over the last 10 years in our reference centre. MATERIAL AND METHODS A descriptive monocentric retrospective study analysed routine care data extracted from our computer files. Patients labelled with a chronic hepatic disease were included. Biological, clinical and survival rate were researched. Drug-drug and drug-disease interactions were compiled and analysed using the exposure ratio, according to the Child-Pugh scale. RESULTS Eighteen patients were included, for 28 presentations. Twelve were Child-Pugh B or C. Only two out of the 18 patients had their antimicrobial dosage adjusted. No patient who had not received the recommended dose adjustment was admitted to the emergency department or for consultation for an antibiotic-related adverse event. During the 1st year, two patients (11.1 %) required hospitalization for revision surgery. Neither relapsed a second time. Six patients (33.3 %) died during follow-up, but none of the deaths were related to infection (four cancers, two ischemic events). CONCLUSION We have shown that cirrhotic patients with BJI are infected with the same pathogens as the general population. Dose adjustments remain unclear, and further studies are required. BJI infections are particularly complex, and require enhanced multidisciplinary management.
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Affiliation(s)
- V Tuloup
- Pharmacy Department, CHU Tours, France; Pharmaceutical Science Faculty, Tours University, France; Inserm U1327 ISCHEMIA, Tours University, France.
| | - C Doumit
- Pharmacy Department, CHU Tours, France
| | - M F Lartigue
- Bacteriology-Virology-Hygiene Service, CHU Tours, France; ISP UMR1282 INRAE, Tours University, France; Medicine Faculty, Tours University, France
| | - L R Le Nail
- Medicine Faculty, Tours University, France; Orthopaedic and Traumatology Surgery Service, CHU Tours, France; Inserm U1069 N2C, Tours University, France
| | - M Lacasse
- Tropical and Infectious Disease Service, CHU Tours, France
| | - A Lemaignen
- Medicine Faculty, Tours University, France; Tropical and Infectious Disease Service, CHU Tours, France
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Kinnard MJ, Cohen JS, Quan T, Foran JR, Sheth NP. Liver Disease Increases the Risk of Postoperative Complications in Patients Undergoing Aseptic Revision Total Hip and Knee Arthroplasty. Arthroplast Today 2024; 29:101516. [PMID: 39363937 PMCID: PMC11447298 DOI: 10.1016/j.artd.2024.101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 07/07/2024] [Accepted: 08/09/2024] [Indexed: 10/05/2024] Open
Abstract
Background Due to the multiorgan effects of liver disease, surgical patients with liver disease have an increased risk of perioperative complications. With revision total hip and knee arthroplasty surgeries increasing, it is important to determine the effects of liver disease in this patient population. The purpose of this study was to evaluate the impact of underlying liver disease on postoperative outcomes following revision total joint arthroplasty (TJA). Methods The National Surgical Quality Improvement Program database was used to identify patients undergoing aseptic revision TJA from 2006-2019 and group them based on liver disease. The presence of liver disease was assessed by calculating the Model for End-Stage Liver Disease-Sodium score. Patients with a Model for End-Stage Liver Disease-Sodium score of > 10 were classified as having underlying liver disease. In this analysis, differences in demographics, comorbidities, and postoperative complications were assessed. Results Of 7102 patients undergoing revision total hip arthroplasty, 11.6% of the patients had liver disease. Of 8378 patients undergoing revision total knee arthroplasty, 8.4% of the patients had liver disease. Following adjustment on multivariable regression analysis, patients with liver disease undergoing revision total hip arthroplasty or revision total knee arthroplasty had an increased risk of major complications, wound complications, septic complications, bleeding requiring transfusion, extended length of stay, and readmission compared to those without liver disease. Conclusions Patients with liver disease have an increased risk of complications following revision TJA. A multidisciplinary team approach should be employed for preoperative optimization and postoperative management of these vulnerable patients to improve outcomes and decrease the incidence and severity of complications. Level of evidence This is retrospective cohort study and is level 3 evidence.
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Affiliation(s)
- Matthew J. Kinnard
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jordan S. Cohen
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Theodore Quan
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC, USA
| | | | - Neil P. Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Lan R, Stiles ER, Ward SA, Lajam CM, Bosco JA. Patients With Moderate to Severe Liver Cirrhosis Have Significantly Higher Short-Term Complication Rates Following Total Knee Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2024; 39:1736-1740. [PMID: 38280615 DOI: 10.1016/j.arth.2024.01.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA). METHODS A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities. RESULTS Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P = .036) complications, 30-day overall complications (75 versus 33.33%, P = .042), and 90-day overall complications (75 versus 33.33%, P = .042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P > .05). CONCLUSIONS Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care.
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Affiliation(s)
- Rae Lan
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Elizabeth R Stiles
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Spencer A Ward
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Chiu AK, Cuero KJ, Agarwal AR, Fuller SI, Kreulen RT, Best MJ, Srikumaran U. The association of alcohol use disorder with revision rates and post-operative complications in total shoulder arthroplasty. Shoulder Elbow 2024; 16:250-257. [PMID: 38818104 PMCID: PMC11135189 DOI: 10.1177/17585732231165526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 06/01/2024]
Abstract
Background Alcohol use disorder (AUD) is the most prevalent substance use disorder in the United States. However, the current literature on AUD as a preoperative risk factor for Total Shoulder Arthroplasty (TSA) outcomes is limited. The purpose of this study was to identify the association of AUD with revision rates and 90-day postoperative complications in TSA. Methods A retrospective study was conducted using the PearlDiver database. Patients diagnosed with AUD were identified. Patients in remission or with underlying cirrhosis were excluded. Outcomes included 2-year revision, 90-day readmission, 90-day emergency, and 90-day post-operative medical complications. Analysis was performed with univariate chi-squared tests followed by multivariable logistic regression. Results A total of 59,261 patients who underwent TSA for osteoarthritis were identified, with 1522 patients having a diagnosis of AUD. Multivariable logistic regression showed that patients with AUD were more likely to undergo 2-year all-cause revision (OR = 1.49, p = 0.007), 2-year aseptic revision (OR = 1.47, p = 0.014), 90-day hospital readmission (OR = 1.57, p = 0.015), and 90-day transient mental disorder (OR = 2.13, p = 0.026). Conclusions AUD is associated with increased rates of 2-year revision surgery, as well as 90-day readmission and 90-day transient mental disorder following primary TSA for osteoarthritis. These findings may assist orthopedic surgeons in counseling patients with AUD during the pre-operative course.
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Affiliation(s)
- Anthony K Chiu
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC, USA
| | - Kendrick J Cuero
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC, USA
| | - Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC, USA
| | - Samuel I Fuller
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC, USA
| | - R Timothy Kreulen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Srikrishnaraj A, Lanting BA, Burton JP, Teeter MG. The Microbial Revolution in the World of Joint Replacement Surgery. JB JS Open Access 2024; 9:e23.00153. [PMID: 38638595 PMCID: PMC11023614 DOI: 10.2106/jbjs.oa.23.00153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
Background The prevalence of revision surgery due to aseptic loosening and periprosthetic joint infection (PJI) following total hip and knee arthroplasty is growing. Strategies to prevent the need for revision surgery and its associated health-care costs and patient morbidity are needed. Therapies that modulate the gut microbiota to influence bone health and systemic inflammation are a novel area of research. Methods A literature review of preclinical and clinical peer-reviewed articles relating to the role of the gut microbiota in bone health and PJI was performed. Results There is evidence that the gut microbiota plays a role in maintaining bone mineral density, which can contribute to osseointegration, osteolysis, aseptic loosening, and periprosthetic fractures. Similarly, the gut microbiota influences gut permeability and the potential for bacterial translocation to the bloodstream, increasing susceptibility to PJI. Conclusions Emerging evidence supports the role of the gut microbiota in the development of complications such as aseptic loosening and PJI after total hip or knee arthroplasty. There is a potential for microbial therapies such as probiotics or fecal microbial transplantation to moderate the risk of developing these complications. However, further investigation is required. Clinical Relevance Modulation of the gut microbiota may influence patient outcomes following total joint arthroplasty.
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Affiliation(s)
- Arjuna Srikrishnaraj
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Brent A. Lanting
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Jeremy P. Burton
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Matthew G. Teeter
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
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Wilczyński M, Bieniek M, Krakowski P, Karpiński R. Cemented vs. Cementless Fixation in Primary Knee Replacement: A Narrative Review. MATERIALS (BASEL, SWITZERLAND) 2024; 17:1136. [PMID: 38473607 DOI: 10.3390/ma17051136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
Knee osteoarthritis (OA) is one of the leading causes of disability around the globe. Osteoarthritis is mainly considered a disease affecting the elderly. However, more and more studies show that sports overuse, obesity, or congenital disorders can initiate a pathologic cascade that leads to OA changes in the younger population. Nevertheless, OA mostly affects the elderly, and with increasing life expectancy, the disease will develop in more and more individuals. To date, the golden standard in the treatment of the end-stage of the disease is total joint replacement (TJR), which restores painless knee motion and function. One of the weakest elements in TJR is its bonding with the bone, which can be achieved by bonding material, such as poly methyl-methacrylate (PMMA), or by cementless fixation supported by bone ingrowth onto the endoprosthesis surface. Each technique has its advantages; however, the most important factor is the revision rate and survivor time. In the past, numerous articles were published regarding TJR revision rate, but no consensus has been established yet. In this review, we focused on a comparison of cemented and cementless total knee replacement surgeries. We introduced PICO rules, including population, intervention, comparison and outcomes of TJR in a PubMed search. We identified 783 articles published between 2010 and 2023, out of which we included 14 in our review. Our review reveals that there is no universally prescribed approach to fixate knee prostheses. The determination of the most suitable method necessitates an individualized decision-making process involving the active participation and informed consent of each patient.
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Affiliation(s)
- Mikołaj Wilczyński
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Michał Bieniek
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Przemysław Krakowski
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
- Department of Trauma Surgery and Emergency Medicine, Medical University of Lublin, Staszica 11, 20-081 Lublin, Poland
| | - Robert Karpiński
- Department of Machine Design and Mechatronics, Faculty of Mechanical Engineering, Lublin University of Technology, Nadbystrzycka 36, 20-618 Lublin, Poland
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Ratnakar V, Jose A, Pawar S, Karumuri K, Masilamani ABS, Reddy AVG. Impact of Hepatitis B on Complications and Functional Outcomes in Patients Undergoing TKR. Indian J Orthop 2024; 58:18-23. [PMID: 38161398 PMCID: PMC10754784 DOI: 10.1007/s43465-023-01040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 10/28/2023] [Indexed: 01/03/2024]
Abstract
Background In India, infected patients with hepatitis B virus (HBV) undergoing total knee replacement (TKA) are increasing. It is recognized that patients with HBV infection are more susceptible to complications after surgery. To evaluate the effect of HBV infection on complications and functional outcome after TKA was the aim of this study. Methods This is the retrospective observation analysis of patients who underwent primary total knee replacement in our hospital from 2017 to 2019. A total of 92 patients were included in the study, of which 46 patients were asymptomatic HBV-positive, and these 46 patients were compared with a matched cohort of another 46 patients who were non-HBV. Results A total of 92 patients were analyzed (asymptomatic HBV n = 46, non-HBV n = 46). The incidence rate of total complications in patients undergoing TKA with asymptomatic HBV was 19.57% compared to 4.3% in non-HBV (p < 0.001). Applied with regression models, patients with HBV had an 8.6% increased risk of surgical complication which included one peri-prosthetic joint infection, three wound dehiscence compared with the non-HBV group which had 2.17% surgical complications (one wound dehiscence). Medical complications were higher in asymptomatic HBV group with 10.87% (which includes one pulmonary embolism, two DVT, and two strokes). In comparison with the non-HBV group which had 2.17% medical complications (one DVT), asymptomatic HBV group had 5.35-fold (95% CI 1.09-26.33; p < 0.01) increase in overall complications. Post-TKA surgical complications are 4.29-fold (95% CI 0.46-39.91; p < 0.01) higher compared to non-HBV group. Conclusion Our study showed asymptomatic hepatitis B patients are at an increased risk of complications (peri-prosthetic joint infections and wound dehiscence) compared to normal patients. In hepatitis B and non-hepatitis B patients, functional outcomes in terms of OKS are comparable.
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Affiliation(s)
- V. Ratnakar
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Ankit Jose
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Sawankumar Pawar
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - Kishore Karumuri
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - A. B. Suhas Masilamani
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
| | - A. V. Gurava Reddy
- Department of Orthopedics, Sunshine Hospitals, PG Road, Secunderabad, 500003 Telangana India
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Liu SH, Burgan J, Ling K, Loyst RA, Tantone R, Komatsu DE, Wang ED. Aspartate Aminotransferase-to-Platelet Ratio Index Suggestive of Liver Dysfunction Predicts Early Complications After Open Reduction Internal Fixation of Distal Radius Fractures. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:1-5. [PMID: 38313624 PMCID: PMC10837168 DOI: 10.1016/j.jhsg.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/24/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose Aspartate aminotransferase-to-platelet ratio index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy, which is resource-intensive and invasive. The purpose of this study was to investigate the association between preoperative APRI and 30-day postoperative complications after isolated open reduction internal fixation (ORIF) of distal radius fractures (DRFs). Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent isolated ORIF of DRFs between 2015 and 2021. The study population was divided into two groups on the basis of preoperative APRI: normal/reference (APRI, <0.5) and liver dysfunction (APRI, ≥0.5). Information on patient demographics, comorbidities, and 30-day postoperative complications after isolated ORIF of DRFs was collected. Multivariate logistic regression analysis was performed to investigate the relationship between preoperative APRI and postoperative complications. Results Compared to patients with normal APRI, patients with preoperative APRI associated with liver dysfunction were significant for male sex (P < .001), younger age (P < .001), American Society of Anesthesiologists classification grade ≥3 (P < .001), being smokers (P < .001), and having comorbid diabetes (P = .002) and bleeding disorders (P < .001). Preoperative APRI associated with liver dysfunction was independently associated with a greater likelihood of any complications (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.19-1.87; P < .001), nonhome discharge (OR, 1.62; 95% CI, 1.15-2.27; P = .005), and a length of stay of >2 days (OR, 1.70; 95% CI, 1.32-2.20; P < .001). Conclusions Aspartate aminotransferase-to-platelet ratio index values associated with liver dysfunction were associated with an increased rate of early postoperative complications after DRF ORIF. Clinical relevance This study suggests APRI's utility as a cost-effective, noninvasive measure of liver function that physicians can use before surgery to better identify surgical candidates with DRFs and suspicion of liver dysfunction. Type of study/level of evidence Prognostic III.
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Affiliation(s)
- Steven H. Liu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - Jane Burgan
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - Kenny Ling
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - Rachel A. Loyst
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - Ryan Tantone
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY
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Ahmed M, Abumoawad A, Jaber F, Elsafy H, Alsakarneh S, Al Momani L, Likhitsup A, Helzberg JH. Safety and outcomes of hip and knee replacement surgery in liver transplant recipients. World J Orthop 2023; 14:784-790. [DOI: 10.5312/wjo.v14.i11.784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/13/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Liver transplant (LT) is becoming increasingly common with improved life expectancy. Joint replacement is usually a safe procedure; however, its safety in LT recipients remains understudied.
AIM To evaluate the mortality, outcome, and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery.
METHODS Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database.
RESULTS A total of 5046119 hip and knee replacement surgeries were identified. 3219 patients had prior LT. Mean age of patients with no history of LT was 67.51 [95% confidence interval (CI): 67.44-67.58], while it was 64.05 (95%CI: 63.55-64.54) in patients with LT. Patients with history of LT were more likely to have prolonged length of hospital stay (17.1% vs 8.4%, P < 0.001). The mortality rate for patients with no history of LT was 0.22%, while it was 0.24% for patients with LT (P = 0.792). Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization: 11.4% as compared to 6.2% in patients without history of LT (P < 0.001). The mortality rate between both groups during readmission was not statistically different (1.9% vs 2%, P = 0.871) respectively.
CONCLUSION Hip and knee replacements in patients with history of LT are not associated with increased mortality; increased re-admissions were more frequent in this cohort of patients. Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.
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Affiliation(s)
- Mohamed Ahmed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO 64108, United States
| | - Abdelrhman Abumoawad
- Department of Vascular Medicine, Boston University, Boston, MA 02215, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO 64108, United States
| | - Hebatullah Elsafy
- Department of Pathology, Kansas University, Kansas City, MO 66160, United States
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO 64108, United States
| | - Laith Al Momani
- Department of Gastroenterology, University of Missouri Kansas City, Kansas City, MO 64110, United States
| | - Alisa Likhitsup
- Department of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, United States
| | - John H Helzberg
- Department of Gastroenterology, University of Missouri Kansas City, Kansas City, MO 64110, United States
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Cheng T, Li G, Mao X, Hao L, Cheng X, Ning H. Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study. Injury 2023:S0020-1383(23)00453-9. [PMID: 37198044 DOI: 10.1016/j.injury.2023.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Osteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery. METHODS The study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls. RESULTS The seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS. CONCLUSION Patients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.
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Affiliation(s)
- Tao Cheng
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, The People's Republic of China.
| | - Guoyong Li
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
| | - Xin Mao
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, The People's Republic of China
| | - Liang Hao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China.
| | - Xigao Cheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
| | - Huiming Ning
- Department of Infectious Disease, Shanghai Eighth People's Hospital, Shanghai, The People's Republic of China
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management. AREAS COVERED This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery. EXPERT OPINION Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Cheng T, Li G, Ning H, Hao L. Antiviral Therapy for Chronic Hepatitis B Infection Improves Outcomes After Total Hip Arthroplasty: A Multicenter Retrospective Study. J Arthroplasty 2023; 38:300-306. [PMID: 35963280 DOI: 10.1016/j.arth.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Previous studies have shown that chronic hepatitis B virus (HBV) infection may place patients at increased risk of postoperative adverse events. However, there is limited information on the effects of antiviral treatment (AVT) on postoperative outcomes following total hip arthroplasties (THAs). METHODS A multicenter retrospective database query was used to identify patients infected with HBV undergoing THAs between 2012 and 2017. All eligible patients were divided into 2 cohorts on the basis of AVT before surgery: the treated group and the untreated group. The treated cohort was matched at a ratio of 1:3 to the untreated cohort by propensity score matching. Operating times, blood losses, all-type complications, surgical complications, lengths of stay, 90-day readmissions, unplanned reoperations, and implant revisions were compared between the 2 cohorts. After these patients were further stratified by liver fibrosis status, multivariate logistic analyses were performed by controlling for differences in demographics and comorbidities. In total, 918 patients chronically infected with HBV were identified. Over four-fifths of these patients (83.0%) did not receive preoperative AVT. Of interest, more than half of the untreated patients (54.1%) were previously undiagnosed. RESULTS The untreated group had significantly longer mean operating time (82 versus 76 minutes, P = .007) and higher mean blood loss (515 versus 465 mL, P = .03) than the treated group. Moreover, they were more prone to experiencing surgical complications (25.4% versus 16.7%, P = .01), longer lengths of stay (6.2 versus 5.4 days, P = .0005), readmissions (12.4% versus 5.8%, P = .02), reoperations (16.7% versus 9.6%, P = .03), and revisions (11.1% versus 4.5%, P = .02). Multivariate regression analyses found that AVT significantly decreased all-type complications, reoperations, and revisions in patients with significant fibrosis (all P < .05). CONCLUSION The AVT of HBV infection prior to THAs could reduce the risk of developing postoperative complications, regardless of the presence of liver fibrosis. This finding emphasizes that surgeons should recommend HBV screening and treatment integrated into preoperative medical optimization.
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Affiliation(s)
- Tao Cheng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, The People's Republic of China
| | - Guoyong Li
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China; Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
| | - Huiming Ning
- Department of Infectious Disease, Shanghai Eighth People's Hospital, Shanghai, The People's Republic of China
| | - Liang Hao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
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Tsagkaris C, Papadakos SP, Moysidis DV, Papazoglou AS, Koutsogianni A, Papadakis M. Hepatomusculoskeletal disorders: Coining a new term might improve the management of the musculoskeletal manifestations of chronic liver disease. World J Gastrointest Pathophysiol 2022; 13:124-127. [PMID: 36161230 PMCID: PMC9350596 DOI: 10.4291/wjgp.v13.i4.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/07/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease can affect many body systems including the musculoskeletal system. The pathogenetic crosstalk between the liver and organs such as the brain and the kidneys has already been described with compound terms merging the organs affected by the pathology, such as the hepatorenal syndrome. Nevertheless, the musculoskeletal manifestations of chronic liver disease have not been coined with such a term to date. Because of this shortage, documenting the musculoskeletal implications of chronic liver disease in both research and clinical practice is challenging. To fill this gap, the authors propose the term hepatomusculoskeletal disorders, a compound term of Greek origin that encompasses all the body structures involved in the aforementioned pathologic crosstalk.
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Affiliation(s)
- Christos Tsagkaris
- Public Health and Policy Working Group, Stg European Student Think Tank, Amsterdam, Netherlands
| | - Stavros P Papadakos
- Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens 18233, Greece
| | - Dimitrios V Moysidis
- Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | | | - Alexandra Koutsogianni
- Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens 18233, Greece
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, University of Witten-Herdecke, Wuppertal 42283, Germany
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Szapary HJ, Monárrez R, Varady NH, Hanna P, Chen AF, Rodriguez EK. Complications and predictors of morbidity for hip fracture surgery in patients with chronic liver disease. Hip Int 2022:11207000221112923. [PMID: 35836328 DOI: 10.1177/11207000221112923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the fact that patients with chronic liver disease (CLD) are at increased risk of complications after a fracture of the hip, there remains little information about the risk factors for acute postoperative complications and their overall outcome.The aim of this study was to describe inpatient postoperative complications and identify predictors of postoperative morbidity. METHODS Patients with CLD who had been treated for a fracture of the hip between April 2005 and August 2019 were identified from a retrospective search of an intramural trauma registry based in the Northeastern United States. Medical records were reviewed for baseline demographics, preoperative laboratory investigations, and outcomes. RESULTS The trauma registry contained 110 patients with CLD who had undergone surgery for a fracture of the hip. Of these, patients with a platelet-count of ⩽100,000/µL were 3.81 (95% CI, 1.59-9.12) times more likely to receive a transfusion than those with a platelet-count of >100,000/µL. Those with a Model for End-stage Liver Disease (MELD) score of >9 were 5.54 (2.33-13.16) times more likely to receive a transfusion and 3.97 (1.06-14.81) times more likely to develop postoperative delirium than those with a MELD score of ⩽9.Of patients without chronic kidney disease, those with a creatinine of ⩾1.2 mg/dL were 6.80 (1.79-25.87) times more likely to develop acute renal failure (ARF) than those with a creatinine of <1.2 mg/dL. In a multivariable model, as MELD score was increased, the odds of developing a composite postoperative complication, which included transfusion, ARF, delirium, or deep wound infection, were 1.29 (1.01-1.66). Other tools used to assess surgical risks, Charlson Comorbidity Index, Elixhauser, and American Society of Anesthesiologist scores, were not predictive. CONCLUSIONS Patients with CLD who undergo surgery for a hip fracture have a high rate of postoperative complications which can be predicted by the preoperative laboratory investigations identified in this study and MELD scores, but not by other common comorbidity indices.
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Affiliation(s)
- Hannah J Szapary
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rubén Monárrez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, MD, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip Hanna
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward K Rodriguez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Koepf US, Scheidt S, Hischebeth GTR, Strassburg CP, Wirtz DC, Randau TM, Lutz P. Increased rate of enteric bacteria as cause of periprosthetic joint infections in patients with liver cirrhosis. BMC Infect Dis 2022; 22:389. [PMID: 35439971 PMCID: PMC9019970 DOI: 10.1186/s12879-022-07379-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/08/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Periprosthetic joint infections (PJI) are a major complication in joint-arthroplasty. Rifampicin is often used as an additional agent to treat PJI, because it penetrates bacterial biofilms. However, rifaximin, belonging to the same antibiotic class as rifampicin, is frequently used to prevent episodes of hepatic encephalopathy in patients with cirrhosis and may induce resistance to rifampicin. The aim of this study was to examine the microbial pattern of periprosthetic joint infections in cirrhotic patients and to test the hypothesis that intake of rifaximin increases the rate of resistance to rifampicin in periprosthetic joint infections. Methods A cohort of cirrhotic patients and PJI (n = 25) was analysed on the characteristics of bacterial isolates from sonication and tissue analysis. In a second step a subgroup analysis on the development of rifampicin resistant bacterial specimens, depending on the intake of rifaximin (8 rifaximin intake patients vs. 13 non rifaximin intake patients) was performed. Results Intestinal bacteria were found in 50% of the specimens, which was significantly more frequent than in a control cohort. By comparison of the single bacterial isolates, rifampicin resistance was detected in 69.2% (9/13) of the rifaximin-intake samples. In contrast, the non-rifaximin-intake isolates only were resistant to rifampicin in 22.2% (4/18) of the cases (p = 0.01). The odds ratio for developing a rifampicin-resistance through rifaximin intake was calculated as OR = 13.5. Conclusion Periprosthetic joint infections have a high incidence of being caused by enteric bacteria in cirrhotic patients. Due to this change in microbial pattern and the innate resistance to rifampicin of most of gram-negative bacteria, the therapy with rifampicin should be carefully considered. The association between the use of rifaximin and developed resistance to rifampicin has a major impact on the treatment of PJI.
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Affiliation(s)
- Uta S Koepf
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany.
| | - Sebastian Scheidt
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Bonn, Germany
| | - Gunnar T R Hischebeth
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Dieter C Wirtz
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Bonn, Germany
| | - Thomas M Randau
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Bonn, Germany
| | - Philipp Lutz
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
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Cheng T, Yang C, Hao L, Cheng X, Hu J, Ren W, Zhang X. Hepatitis C virus infection increases the risk of adverse outcomes following joint arthroplasty: A meta-analysis of observational studies. Orthop Traumatol Surg Res 2022; 108:102947. [PMID: 33930585 DOI: 10.1016/j.otsr.2021.102947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Whether hepatitis C virus (HCV)-positive patients are at risk for increased complications and long hospital stay following total joint arthroplasty (TJA) remains unclear. Therefore we performed a meta-analysis aiming to answer the following question: (1) are there differences in postoperative complications including joint infection and mortality between patients with or without hepatitis C following TJAs? (2) Are patients without HCV be associated with less blood loss, shorter hospital stay, lower readmission rate, higher function scores, lower revision and reoperation rates than patients with HCV? METHODS A meta-analysis was conducted to pool data and quantitatively assessing the association between HCV infection and risks for adverse postoperative outcomes. A systematic search of all published studies concerning HCV and TJA was performed in five bibliographic databases, including PubMed, EMBASE, China National Knowledge Infrastructure, Web of Science, and the Cochrane Library databases. Random-effects meta-analysis of odds ratios (OR) was accomplished according to the classification of adverse events, subgroup analyses were performed based on surgery type. RESULTS Fifteen eligible observational studies were included with a sample size of 9,788,166 patients. Overall pooled data revealed the increased risk of overall complications, including medical and surgical complications, in HCV-positive patients undergoing TJA compared with than in HCV-negative people (OR 1.57; 95%CI: 1.44-1.71 [p<0.00001]). Joint infections were highly common in HCV-positive patients undergoing lower-extremity TJA (OR 2.06; 95%CI: 1.73-2.47 [p<0.00001]). Furthermore, HCV infections were associated with high rates of reoperations and revisions (OR 1.47; 95%CI: 1.40-1.55 [p<0.00001]). CONCLUSIONS Patients with hepatitis C have an increased risk of adverse outcomes post-TJA and a high risk of reoperation and revision that is partially attributed to postoperative complications, particularly joint infections. LEVEL OF EVIDENCE III; systematic review and meta-analysis.
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Affiliation(s)
- Tao Cheng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Shanghai Sixth People's Hospital, No.600 Yishan Road, Xuhui District, 200233 Shanghai, People's Republic of China.
| | - Chao Yang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Shanghai Sixth People's Hospital, No.600 Yishan Road, Xuhui District, 200233 Shanghai, People's Republic of China
| | - Liang Hao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, 330006 Nanchang, People's Republic of China
| | - Xigao Cheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, No.1 Minde Road, Donghu District, 330006 Nanchang, People's Republic of China
| | - Jianjun Hu
- Department of Infectious Disease, Shanghai Jiao Tong University Affiliated Shanghai Sixth People's Hospital, No.600 Yishan Road, Xuhui District, 200233 Shanghai, People's Republic of China
| | - Weiping Ren
- Department of Biomedical Engineering, Wayne State University, 818W. Hancock Avenue, Detroit, MI 48201, USA
| | - Xianlong Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Shanghai Sixth People's Hospital, No.600 Yishan Road, Xuhui District, 200233 Shanghai, People's Republic of China
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Renninger CH, Jaeblon T, Slobogean GP, O'Toole RV, O'Hara NN. Patients With Cirrhosis Who Have a Model for End-stage Liver Disease Sodium Score of 8 or Greater Are at Increased Risk of Poor Outcomes in Operatively Treated Tibia Fractures. Orthopedics 2022; 45:79-85. [PMID: 35021031 DOI: 10.3928/01477447-20220105-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare 30-day readmission rates for cirrhotic and non-cirrhotic patients after tibia fracture fixation by retrospectively identifying all surgically managed tibial plateau, tibial shaft, and pilon fractures from 2010 through 2018 in the National Surgical Quality Improvement Program database (N=14,028). The primary outcome measure was 30-day readmission rates. Secondary outcome measures included 30-day rates of reoperation, length of stay, pulmonary embolism, deep venous thrombosis, and wound complications, including deep or superficial infection. Cirrhotic patients (n=665) and non-cirrhotic patients (n=13,363) were identified using the aspartate aminotransferase to platelet ratio index test. Cirrhotic patients were more likely to have preoperative ascites, renal failure, bleeding disorders, and preoperative transfusions. No differences were reported between the two groups in readmission rate or any of the secondary outcome measures, except that cirrhotic patients' length of stay was longer by 0.5 day. Stratification of the cirrhotic cohort demonstrated that a Model for End-stage Liver Disease sodium (MELD-Na) score of 8 or greater was associated with a 4.1-fold increase in the rate of readmission (5.9% vs 1.5%; P<.01). No other differences were identified based on MELD-Na score stratification. Patients with advanced cirrhosis (MELD-Na score ≥8) have an increased risk of 30-day readmission after tibia fracture surgery. Cirrhosis associated with a lower MELD-Na score might not significantly increase the risk of 30-day complications in patients with tibia fractures. [Orthopedics. 2022;45(2):79-85.].
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Shah NV, Huddleston HP, Wolff DT, Newman JM, Pivec R, Naziri Q, Shah VR, Maheshwari AV. Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review. Orthopedics 2022; 45:e67-e72. [PMID: 34978509 DOI: 10.3928/01477447-20211227-03] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This systematic review evaluated the combined effects of obesity and surgical approach on periprosthetic joint infection (PJI) rates after total hip arthroplasty (THA). Wound complication and PJI rates were elevated among patients with body mass index (BMI) of 30 kg/m2 or greater and 35 kg/m2 or greater, respectively, with the direct anterior approach (DAA). A BMI of 30 kg/m2 or greater also increased the risk of PJI with the posterior approach. Patients with BMI of 30 kg/m2 or greater undergoing anterolateral approach THA did not have increased risk of PJI. Patients with elevated BMI (≥30 kg/m2) are at risk for PJI, regardless of approach. Patients undergoing DAA THA who have BMI of 35 kg/m2 or greater may have an increased risk of PJI compared with those undergoing THA with other approaches. [Orthopedics. 2022;45(2):e67-e72.].
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Ranjan R, Rampal S, Jaiman A, Ali Tokgöz M, Kit Koong J, Ramayah K, Rajaram R. Common musculoskeletal disorders in chronic liver disease patients. Jt Dis Relat Surg 2021; 32:818-823. [PMID: 34842121 PMCID: PMC8650659 DOI: 10.52312/jdrs.2021.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.
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Affiliation(s)
- Rajat Ranjan
- Integral Institute of Medical Sciences & Research, Integral University, Lucknow, India
| | - Sanjiv Rampal
- Department of Orthopaedics and Traumatology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
| | - Ashish Jaiman
- Vardhman Mahavir Medical College & Safdarjung Hospital, Central Institute of Orthopaedics, New Delhi, India
| | - Mehmet Ali Tokgöz
- Ankara Keçiören Training and Research Hospital, Consultant Orthopaedic Surgeon, Ankara, Turkey
| | - Jun Kit Koong
- Department of Surgery, Malaya University Medical Faculty, Kuala Lumpur, Malaysia
| | - Kamarajan Ramayah
- Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ruveena Rajaram
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
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Han GJ, Deren ME. A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis. J Arthroplasty 2021; 36:3623-3630. [PMID: 34127348 DOI: 10.1016/j.arth.2021.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/30/2021] [Accepted: 05/13/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population. METHODS A systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4). RESULTS A total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively). CONCLUSION Liver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.
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Affiliation(s)
- George J Han
- University of Massachusetts Medical School, Worcester, MA
| | - Matthew E Deren
- Department of Orthopedics and Rehabilitation, University of Massachusetts Memorial Medical Center, Worcester, MA
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Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis. J Am Acad Orthop Surg 2021; 29:e769-e781. [PMID: 32947345 DOI: 10.5435/jaaos-d-20-00795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/18/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA. METHODS We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users. RESULTS A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02). DISCUSSION Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.
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22
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Statz JM, Odum SM, Johnson NR, Otero JE. Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous? Arthroplast Today 2021; 10:18-23. [PMID: 34277906 PMCID: PMC8267488 DOI: 10.1016/j.artd.2021.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/18/2022] Open
Abstract
Background There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA. Methods The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m2 and age of 72 years, and 60% of whom were female. Results We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m2, tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001). Conclusions Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient. Level of Evidence IV.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nicholas R Johnson
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Jesse E Otero
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA.,OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
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A Matched Control Analysis on the Effects of Alcohol Use Disorder After Primary Total Knee Arthroplasty in Medicare Patients. J Am Acad Orthop Surg 2021; 29:e593-e600. [PMID: 32991387 DOI: 10.5435/jaaos-d-20-00466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/24/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Several studies have found the negative impact of alcohol use disorder (AUD), most notably coagulation derangements. We sought to investigate the effects of AUD after primary total knee arthroplasty (TKA) for (1) postoperative complications, (2) lengths of stay, and (3) costs of care. METHODS This was a retrospective database analysis of Medicare patients with AUD undergoing primary TKA performed between 2005 and 2014. Patients with AUD were matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 354,690 TKA patients: 59,126 with AUD and 295,564 without AUD. RESULTS Patients with AUD had significantly greater odds ratio (OR) of medical complications, including venous thromboembolism (VTE) within 90 days (OR: 1.41, P < 0.0001) and at 1 year (OR: 1.51, P < 0.0001) and greater 2-year implant-related complications after primary TKA. Furthermore, patients with AUD had significantly longer lengths of stay (4 versus 3 days, P < 0.0001) and incurred a significantly higher episode of care costs ($15,569.76 versus $13,763.06, P < 0.0001). DISCUSSION The present study demonstrated a significant association between AUD and the development of VTE. We hope this research will aid in risk stratification and tailoring of VTE chemoprophylaxis and postoperative management in this at-risk group after TKA. LEVEL OF EVIDENCE Level III.
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Tischler EH, Restrepo C, Ponzio DY, Austin MS. Routine Postoperative Chemistry Panels Are Not Necessary for Most Total Joint Arthroplasty Patients. J Bone Joint Surg Am 2021; 103:968-976. [PMID: 34038395 DOI: 10.2106/jbjs.20.01530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The routine use of traditional chemistry-7 (chem-7) laboratory tests following total joint arthroplasty (TJA) has been called into question with the advent of short-stay procedures. Our objective was to determine the incidence, risk factors, and clinical interventions associated with inpatient abnormal routine postoperative chem-7 panels. METHODS From 2015 to 2017, 3,162 patients underwent a total of 3,721 TJA procedures, including primary total hip arthroplasty (THA) (n = 1,939; 52.1%) or primary total knee arthroplasty (TKA) (n = 1,782; 47.9%). Patients underwent routine preoperative and postoperative chem-7 testing. Clinical interventions were identified. With use of mixed-effects multivariate logistic regression, potential risk factors for abnormal chemistry panel values (including preoperative chem-7 results, type of surgery, age, sex, race, comorbidities, American Society of Anesthesiologists [ASA] score, and medications) were analyzed. RESULTS The rates of abnormal preoperative laboratory results were 3.4% for sodium (Na+), 7.4% for potassium (K+), 15.8% for blood urea nitrogen (BUN), and 26.4% for creatinine (Cr). The incidence of abnormal postoperative results was low for K+ (9.7%) and higher for Na+ (25.6%), BUN (55.6%), and Cr (27.9%). Preoperative abnormal laboratory results were a significant predictor of a postoperative abnormality for Na+ (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.82 to 2.54), K+ (OR = 4.22; 95% CI = 3.03 to 5.88), and Cr (OR = 3.00; 95% CI = 2.45 to 3.68). Bilateral TJA was associated with increased odds of abnormal postoperative Na+ (OR = 1.56; 95% CI = 1.44 to 1.68). Renal disease was associated with increased odds of abnormal postoperative Cr (OR = 15.21; 95% CI = 5.67 to 40.77). Patients taking loop diuretics had increased odds of abnormal postoperative K+ (OR = 2.10; 95% CI = 1.42 to 3.11) and Cr (OR = 2.28; 95% CI = 1.56 to 3.33). Regarding intervention, 6.7% of hypokalemic patients received potassium chloride (KCl) fluid/tablets. Forty percent of hyponatremic patients received sodium chloride (NaCl) fluid/tablets. The electrolyte-related medicine consultation rate was 0.3% (13 of 3,721). CONCLUSIONS On the basis of our findings, we recommend postoperative chem-7 testing for patients with an abnormal preoperative laboratory result (Na+, K+, BUN, Cr), preexisting renal disease, bilateral TJA, and prescribed angiotensin-converting enzyme inhibitors (ACE), angiotensin II receptor blockers (ARB), and diuretics. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric H Tischler
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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25
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A Novel Biofilm-Disrupting Wound Care Technology for the Prevention of Surgical Site Infections Following Total Joint Arthroplasty: A Conceptual Review. Surg Technol Int 2021. [PMID: 34005832 DOI: 10.52198/21.sti.38.os1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical site infections (SSIs) are a major driver for increased costs following lower extremity joint arthroplasty procedures. It has been estimated that these account for over $2 billion in annual costs in the United States. While many of the current strategies for the prevention and treatment of SSIs target planktonic bacteria, 80 to 90% of bacterial pathogens exist in a sessile state. These sessile bacteria can produce extracellular polymeric substance (EPS) as protective barriers from host immune defenses and antimicrobial agents and thus, can be exceedingly difficult to eradicate. A novel wound care gel that disrupts the EPS and destroys the inciting pathogens has been developed for the treatment and prevention of biofilm-related infections. This is achieved by the simultaneous action of four key ingredients: (1) citric acid; (2) sodium citrate; (3) benzalkonium chloride; and (4) polyethylene glycol. Together, these constituents create a high osmolarity, pH-controlled environment that deconstructs and prevents biofilm formation, while destroying pathogens and promoting a moist environment for optimal wound healing. The available clinical evidence demonstrating the efficacy of this technology has been summarized, as well as the economic implications of its implementation and the authors' preferred method of its use. Due to the multifaceted burden associated with biofilm-producing bacteria in arthroplasty patients, this technology may prove to be beneficial for patients who have higher risks for infection, or perhaps, as a prophylactic measure to prevent infections for all patients.
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Salomon B, Krause PC, Dasa V, Shi L, Jones D, Chapple AG. The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas. Arthroplast Today 2021; 7:200-207. [PMID: 33553550 PMCID: PMC7856322 DOI: 10.1016/j.artd.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Background Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA. Methods Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year. Results Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA. Conclusion Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.
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Affiliation(s)
- Brett Salomon
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Deryk Jones
- Department of Orthopaedic Surgery, Section of Sports Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Andrew G Chapple
- Department of Public Health and Biostatistics, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Lu Y, Lin CC, Stepanyan H, Alvarez AP, Bhatia NN, Kiester PD, Rosen CD, Lee YP. Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion. Global Spine J 2020; 10:851-855. [PMID: 32905718 PMCID: PMC7485078 DOI: 10.1177/2192568219880823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
STUDY DESIGN Retrospective large database study. OBJECTIVE To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery. METHODS Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion. RESULTS A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001). CONCLUSIONS Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.
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Affiliation(s)
- Young Lu
- University of California at Irvine, Orange, CA, USA
| | | | | | | | | | | | | | - Yu-Po Lee
- University of California at Irvine, Orange, CA, USA,Yu-Po Lee, Department of Orthopaedics, University of California at Irvine, 101 The City Drive South, Orange, CA 92868, USA.
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Lall AC, Secretov E, Battaglia MR, Maldonado DR, Perets I, Domb BG. Effect of alcohol consumption on patient-reported outcomes in hip arthroscopy: a matched controlled study with minimum 2-year follow-up. Hip Int 2020; 30:457-468. [PMID: 31167582 DOI: 10.1177/1120700019853554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is a paucity of literature examining the effects of alcohol consumption on patient-reported outcomes (PROs) after hip arthroscopy. The purpose of this study was to report 2-year outcomes of hip arthroscopy in patients who consume alcohol compared to patients who abstain. METHODS Registry data were prospectively collected and retrospectively reviewed to identify heavy drinkers at the time of primary hip arthroscopy. Patients were matched 1:1 (heavy drinkers:non-drinkers) based on age, sex, BMI, acetabular Outerbridge grade, and capsular treatment. All patients were assessed with 4 validated PROs: mHHS, NAHS, HOS-SSS, and iHOT-12. Pain was estimated with VAS. RESULTS 42 patients were pair matched in each group (heavy drinkers:non-drinkers). Both groups demonstrated significant improvement for all PROs and VAS. Heavy drinkers reported lesser improvement in HOS-SSS (p = 0.0169), smaller decrease in VAS (p = 0.0157), and lower final scores on iHOT-12 (p = 0.0302), SF-12 mental (p = 0.0086), and VR-12 mental (p = 0.0151). Significantly fewer patients in the heavy-drinking group reached PASS for mHHS (p = 0.0464). Odds of achieving PASS for mHHS was 2.5 times higher for patients who abstain from alcohol. The rates of revision hip arthroscopy and conversion to total hip arthroplasty were not statistically different between groups. CONCLUSION While hip arthroscopy may still yield clinical benefit in drinkers, patients who consume heavy amounts of alcohol may ultimately achieve an inferior functional status and should be counselled on drinking cessation to optimise their results.
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Affiliation(s)
- Ajay C Lall
- American Hip Institute, Des Plaines, IL, USA
| | | | | | | | - Itay Perets
- Hadassah Hebrew University Hospital, Jerusalem, Israel
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Kim JH, Lee DH. Are high-risk patient and revision arthroplasty effective indications for closed-incisional negative-pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta-analysis. Int Wound J 2020; 17:1310-1322. [PMID: 32406175 DOI: 10.1111/iwj.13393] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/02/2020] [Indexed: 12/21/2022] Open
Abstract
To determine the effective indications of closed-incisional negative-pressure wound therapy (ciNPWT) following total hip or knee arthroplasty, this systematic review and meta-analysis was conducted. The systematic search was performed on MEDLINE, Embase, and Cochrane Library, and 11 studies were included. The studies comparing between ciNPWT and conventional dressings were categorised into following subgroups based on patient risk and revision procedures: routine vs high-risk patient; primary vs revision arthroplasty. Pooled estimates were calculated for wound complication and surgical site infection (SSI) rates in the subgroup analyses using Review Manager. In high-risk patients, the overall rates of wound complication (odds ratio [OR] = 0.38; 95% confidence interval [CI] 0.15-0.93; P = .030) and SSI (OR = 0.24; 95% CI = 0.09-0.64; P = .005) were significantly lower in the ciNPWT; however, there were no differences in routine patients. In cases involving revision arthroplasties, the overall rates of wound complication (OR = 0.33; 95% CI = 0.18-0.62; P < .001) and SSI (OR = 0.26; 95% CI = 0.11-0.66; P = .004) were significantly lower in the ciNPWT; however, there were no differences in cases involving primary arthroplasties. In summary, ciNPWT showed a positive effect in decreasing the rates of wound complication and SSI in high-risk patients and in revision arthroplasties.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Palacios-Flores M, Alfaro-Fernandez P, Gutarra-Vilchez R, Suarez-Peña R. Factors associated with infection of primary total knee prosthesis in older adults in a referral hospital in Peru. 2012–2015. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020. [DOI: 10.1016/j.recote.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kim CW, Kim HJ, Lee CR, Wang L, Rhee SJ. Effect of chronic kidney disease on outcomes of total joint arthroplasty: a meta-analysis. Knee Surg Relat Res 2020; 32:12. [PMID: 32660587 PMCID: PMC7219208 DOI: 10.1186/s43019-020-0029-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This meta-analysis was conducted to evaluate the differences in preoperative comorbidities, postoperative mortality, the rate of periprosthetic joint infection (PJI), and revision rate after total joint arthroplasty (TJA) between patients with chronic kidney disease (CKD)(CKD group) and patients with normal kidney function (non-CKD group). METHODS We searched MEDLINE, EMBASE, and the Cochrane Library for studies assessing the effect of CKD on TJA outcome. This meta-analysis included studies that (1) compared the outcomes of TJA between the CKD and non-CKD groups; (2) compared the outcomes of TJA based on CKD stage; and (3) evaluated the risk factors for morbidity or mortality after TJA. We compared the mortality, PJI, and revision rate between CKD and non-CKD groups, and between dialysis-dependent patients (dialysis group) and non-dialysis-dependent patients (non-dialysis group). RESULTS Eighteen studies were included in this meta-analysis. In most studies that assessed preoperative comorbidities, the number and severity of preoperative comorbidities were reported to be higher in the CKD group than in the non-CKD group. The risk of mortality was found to be higher in the CKD and dialysis groups compared with the respective control groups. In the studies based on administrative data, the unadjusted odds ratio (OR) of PJI was significantly higher in the CKD group than in the non-CKD group; however, no significant difference between the groups was noted in the adjusted OR. After total hip arthroplasty (THA), the risk of PJI was higher in the dialysis group than in the non-dialysis group. No significant difference was noted between the groups in the rate of PJI following total knee arthroplasty. The revision rate did not significantly differ between the CKD and non-CKD groups in the studies that were based on administrative data. However, the unadjusted OR was significantly higher in the dialysis group than in the non-dialysis group. CONCLUSIONS Preoperative comorbidities and mortality risk were higher in the CKD and dialysis groups than in their respective control groups. The risk of revision was greater in the dialysis group than in the non-dialysis group, and the risk of PJI in the dialysis group became even greater after THA. Surgeons should perform careful preoperative risk stratification and optimization for patients with CKD scheduled to undergo TJA.
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Affiliation(s)
- Chang-Wan Kim
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, 47392, Republic of Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, 47392, Republic of Korea.
| | - Lih Wang
- Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Seung Joon Rhee
- Department of Orthopedic Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Palacios-Flores MA, Alfaro-Fernandez PR, Gutarra-Vilchez RB, Suarez-Peña R. Factors associated with infection of primary total knee prosthesis in older adults in a referral hospital in Peru. 2012-2015. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:191-198. [PMID: 31987781 DOI: 10.1016/j.recot.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 08/19/2019] [Accepted: 11/15/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine the risk factors associated with prosthetic knee infection in elderly patients in a referral hospital in Peru. PATIENTS AND METHODS A case and control study was performed. The calculated sample was 44 cases and 132 controls. The data were collected retrospectively from clinical records. U-Mann Whitney and Chi-square tests were performed in the comparison of cases and controls. Odds ratios (OR) were calculated in a binary logistic regression analysis to identify the risk factors, a P<.05 and a 95% confidence interval (CI) were considered significant. RESULTS Significant (P<.05) risk factors evidenced in the bivariate analysis were obesity (OR=9.72; 95%CI: 4.47-21.14), smoking (OR=4.06; 95%CI: 1.59-10.39), rheumatoid arthritis (OR=4.66; 95%CI: 1.52-14.32), diabetes mellitus type2 (OR=5.63; 95%CI: 2.69-11.78), persistent drainage (OR=9.27; 95%CI: 3.85-22.31), superficial infection (OR=6.87; 95%CI: 3.25-14.49) and prolonged hospital stay (OR=4.67; 95%CI: 2.26-9.64). In the multivariate analysis where it was adjusted for confounding variables, it was determined that risk factors were obesity (ORa=9.14; 95%CI: 3.28-25.48), diabetes mellitus (ORa=3.77; 95%CI: 1.38-10.32), persistent drainage (ORa=4.64; 95%CI: 1.03-20.80) and superficial wound infection (ORa=27.35; 95%CI: 2.57-290.64). CONCLUSIONS Risk factors for prosthetic knee infection identified in this study are preventable. The main risk factors were obesity, diabetes mellitus type2, superficial wound infection and persistent drainage, which were considered together or separately to be risk factors in the population studied.
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Affiliation(s)
- M A Palacios-Flores
- Unidad de Rodilla, Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú.
| | | | | | - R Suarez-Peña
- Unidad de Rodilla, Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
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Lespasio M, Mont M, Guarino A. Identifying Risk Factors Associated With Postoperative Infection Following Elective Lower-Extremity Total Joint Arthroplasty. Perm J 2020; 24:1-3. [PMID: 33482967 DOI: 10.7812/tpp/20.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This article addresses the importance of identifying risk factors associated with postoperative infection following elective lower-extremity total joint arthroplasty. Specifically, this review discusses risk factors recognized by the American Academy of Orthopaedic Surgeons that should be carefully considered and assessed by the orthopaedic team in collaboration with the primary care provider before proceeding with surgery.
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Affiliation(s)
- Michelle Lespasio
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Michael Mont
- Northwell Health Physician Partners Orthopaedic Institute at Lenox Hill, Lenox Hill Hospital, New York, NY
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Impact of chronic kidney disease on outcomes after total joint arthroplasty: a meta-analysis and systematic review. INTERNATIONAL ORTHOPAEDICS 2019; 44:215-229. [DOI: 10.1007/s00264-019-04437-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/15/2019] [Indexed: 12/25/2022]
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Yan CH, Arciola CR, Soriano A, Levin LS, Bauer TW, Parvizi J. Team Approach: The Management of Infection After Total Knee Replacement. JBJS Rev 2019; 6:e9. [PMID: 29664872 DOI: 10.2106/jbjs.rvw.17.00058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chun Hoi Yan
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Onochie E, Kayani B, Dawson-Bowling S, Millington S, Achan P, Hanna S. Total hip arthroplasty in patients with chronic liver disease: A systematic review. SICOT J 2019; 5:40. [PMID: 31674904 PMCID: PMC6824439 DOI: 10.1051/sicotj/2019037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Chronic liver disease (CLD) is a significant and increasingly prevalent co-morbidity in patients undergoing total hip arthroplasty (THA). These patients may develop metabolic bone disease (MBD) and systemic dysfunction, which pose challenges to THA surgery. This systematic review of literature aims to examine clinical outcomes and complications in patients with CLD undergoing THA and provide evidence-based approaches as to the optimization of their perioperative care. METHODS A Pubmed search was performed, identifying eight studies on 28 514 THAs for inclusion. Two additional studies reported on 44 patients undergoing THA post liver transplant. These were reviewed separately. RESULTS Increased early perioperative complications are reported recurrently. Review of long-term complications demonstrates an increased postoperative infection rate of 0.5% (p < 0.001) and perioperative mortality of 4.1% (p < 0.001). The need for revision surgery is more frequent at 4% (p < 0.001). Aetiology of need for revision surgery included; periprosthestic infection (70%), aseptic loosening (13%), instability (13%), periprosthetic fracture (2%) and liner wear (2%). THA in patients with liver transplants seems to offer functional improvement; however, no studies have formally assessed functional outcomes in the patient with active CLD. DISCUSSION A multidisciplinary perioperative approach is suggested in order to minimize increased complication risks. Specific measures include optimizing haemoglobin and taking measures to reduce infection. This review also highlights gaps in available literature and guides future research to appraise functional outcomes, further detail long-term failure reasons and study any differences in outcomes and complications based on the range of operative approaches and available implant choices.
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Affiliation(s)
- Elliot Onochie
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
| | - Sebastian Dawson-Bowling
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
| | - Steven Millington
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
| | - Pramod Achan
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
| | - Sammy Hanna
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1BB, UK
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Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample. J Clin Gastroenterol 2019; 53:e356-e361. [PMID: 30001287 PMCID: PMC6443495 DOI: 10.1097/mcg.0000000000001091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. METHODS We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. RESULTS There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. CONCLUSIONS Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.
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Association of hepatitis B infection with high-risk complications in total joint arthroplasty. BMC Musculoskelet Disord 2019; 20:163. [PMID: 30971239 PMCID: PMC6458739 DOI: 10.1186/s12891-019-2535-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 03/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background An increasing number of patients with hepatitis B virus (HBV) infection are undergoing total joint arthroplasty (TJA) surgery in China. Less attention is provided to the special populations and the purpose of this study is to assess the effect of HBV infection on the prognosis TJAs. Methods We retrospectively reviewed patients who underwent elective primary hip and knee arthroplasties in Shanghai Huashan Hospital from 2013 to 2016. Non-hepatitis B cohort was built to match the case cohort to identify whether HBV infection was a risk factor associated with postoperative complications. A total number of 196 patients who underwent primary TJAs were involved in the study, including 49 patients with hepatitis B and 147 non-hepatitis B subjects. Results Among all the patients with TJAs, 5.5% of patients were infected with HBV for the first time. The incidence rate of complications in patients after arthroplasty with hepatitis B infection was significantly higher than that in patients without hepatitis B (10.2% compared to 4.7%, P < 0.01). Surgical related complications (6.1% compared to 3.4%) and general medical complications (4.1% compared to 1.3%) were higher than those in non-B hepatitis group. Compared with non-B hepatitis group, the overall risk of hepatitis B infection increased by 25% (95% CI, 1.04–1.46; p < 0.01). Similar results were obtained for medical and surgical complications. HBV infection presented a 31% increased risk (95% CI, 1.02–1.62; p < 0.01) for medical complication and an 18% increased risk (95% CI, 1.10–1.26; p < 0.01) for surgical complication. No statistical difference was found between the surgical methods and sex. However, a significant difference of C-reactive protein (CRP) level was found between HBV infection group and the matched non-infected group (P < 0.01). Conclusion This is the first study to investigate the risk of perioperative complications of hepatitis B in Chinese TJAs patients. In consideration of the large population of HBV infection in China, more attention and medical care should be provided to patients with HBV infection who need to undergo TJA operation.
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Cizmic Z, Feng JE, Huang R, Iorio R, Komnos G, Kunutsor SK, Metwaly RG, Saleh UH, Sheth N, Sloan M. Hip and Knee Section, Prevention, Host Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S255-S270. [PMID: 30348549 DOI: 10.1016/j.arth.2018.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Bonasia DE, Palazzolo A, Cottino U, Saccia F, Mazzola C, Rosso F, Rossi R. Modifiable and Nonmodifiable Predictive Factors Associated with the Outcomes of Total Knee Arthroplasty. JOINTS 2019; 7:13-18. [PMID: 31879725 PMCID: PMC6930124 DOI: 10.1055/s-0039-1678563] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
Total knee arthroplasty (TKA) is a valuable treatment option for advanced osteoarthritis in patients unresponsive to conservative treatments. Despite overall satisfactory results, the rate of unsatisfied patients after TKA remains high, ranging from 5 to 40%. Different modifiable and nonmodifiable prognostic factors associated with TKA outcomes have been described. The correction, whenever possible, of modifiable factors is fundamental in preoperative patients' optimization protocols. Nonmodifiable factors can help in predicting the outcomes and creating the right expectations in the patients undergoing TKA. The goal of this review is to summarize the modifiable and nonmodifiable prognostic factors associated with TKA outcomes.
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Affiliation(s)
- Davide E Bonasia
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Anna Palazzolo
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Umberto Cottino
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Francesco Saccia
- Ospedale Torino Nord Emergenza San Giovanni Bosco, SC Ortopedia e Traumatologia, Torino, Italy
| | - Claudio Mazzola
- Ospedali Galliera Genova, SC Ortopedia delle articolazioni, Genoa, Italy
| | - Federica Rosso
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
| | - Roberto Rossi
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Torino, Italy
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Zainul-Abidin S, Amanatullah DF, Anderson MB, Austin M, Barretto JM, Battenberg A, Bedard NA, Bell K, Blevins K, Callaghan JJ, Cao L, Certain L, Chang Y, Chen JP, Cizmic Z, Coward J, DeMik DE, Diaz-Borjon E, Enayatollahi MA, Feng JE, Fernando N, Gililland JM, Goodman S, Goodman S, Greenky M, Hwang K, Iorio R, Karas V, Khan R, Kheir M, Klement MR, Kunutsor SK, Limas R, Morales Maldonado RA, Manrique J, Matar WY, Mokete L, Nung N, Pelt CE, Pietrzak JRT, Premkumar A, Rondon A, Sanchez M, Novaes de Santana C, Sheth N, Singh J, Springer BD, Tay KS, Varin D, Wellman S, Wu L, Xu C, Yates AJ. General Assembly, Prevention, Host Related General: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S13-S35. [PMID: 30360983 DOI: 10.1016/j.arth.2018.09.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kheir MM, Tan TL, Kheir M, Maltenfort MG, Chen AF. Postoperative Blood Glucose Levels Predict Infection After Total Joint Arthroplasty. J Bone Joint Surg Am 2018; 100:1423-1431. [PMID: 30106824 DOI: 10.2106/jbjs.17.01316] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Perioperative hyperglycemia has many etiologies, including medication, impaired glucose tolerance, uncontrolled diabetes mellitus, or stress, the latter of which is common in patients postoperatively. Our study investigated the influence of postoperative blood glucose levels on periprosthetic joint infection after elective total joint arthroplasty to determine a threshold for glycemic control for which surgeons should strive during a patient's hospital stay. METHODS A single-institution retrospective review was conducted on 24,857 primary total joint arthroplasties performed from 2001 to 2015. Of these, 13,196 had a minimum follow-up of 1 year (mean, 5.9 years). Postoperative day 1 morning blood glucose levels were utilized and were correlated with periprosthetic joint infection, as defined by the International Consensus Group on Periprosthetic Joint Infection. Multivariable analysis was used to determine the influence of several important covariates on infection. An alpha level of 0.05 was used to determine significance. RESULTS The rate of periprosthetic joint infection increased linearly from blood glucose levels of ≥115 mg/dL. Multivariable analysis revealed that blood glucose levels were significantly associated with periprosthetic joint infection (p = 0.028). The optimal blood glucose threshold to reduce the likelihood of periprosthetic joint infection was 137 mg/dL. The periprosthetic joint infection rate in the entire cohort was 1.59% (1.46% in patients without diabetes compared with 2.39% in patients with diabetes; p = 0.001). There was no significant association between blood glucose level and periprosthetic joint infection in patients with diabetes (p = 0.276), although there was a linear trend. CONCLUSIONS The relationship between postoperative blood glucose levels and periprosthetic joint infection increased linearly, with an optimal cutoff of 137 mg/dL. Immediate and strict postoperative glycemic control may be critical in reducing postoperative complications, as even mild hyperglycemia was significantly associated with periprosthetic joint infection. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael M Kheir
- Indiana University Department of Orthopaedic Surgery, Indianapolis, Indiana
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew Kheir
- University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Antonia F Chen
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
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Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty. J Arthroplasty 2018. [PMID: 29530518 DOI: 10.1016/j.arth.2018.01.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antibacterial coatings (ABCs) of implants have proven safe and effective to reduce postsurgical infection, but little is known about their possible economic impact on large-scale use. This study evaluated the point of economic balance, during the first year after surgery, and the potential overall annual healthcare cost savings of 3 different antibacterial technologies applied to joint arthroplasty: a dual-antibiotic-loaded bone cement (COPAL G + C), an antibacterial hydrogel coating (DAC), and a silver coating (Agluna). METHODS The variables included in the algorithm were average cost and number of primary joint arthroplasties; average cost per patient of the ABC; incidence of periprosthetic joint infections and expected reduction using the ABCs; average cost of infection treatment and expected number of cases. RESULTS The point of economic balance for COPAL G + C, DAC, and Agluna in the first year after surgery was reached in patient populations with an expected postsurgical infection rate of 1.5%, 2.6%, and 19.2%, respectively. If applied on a national scale, in a moderately high-risk population of patients with a 5% expected postsurgical infection rate, COPAL G + C and DAC hydrogel would provide annual direct cost savings of approximately €48,800,000 and €43,200,000 (€1220 and €1080 per patient), respectively, while the silver coating would be associated with an economic loss of approximately €136,000,000. CONCLUSION This economic evaluation shows that ABC technologies have the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections, provided that the technology is used in the appropriate risk class of patients.
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Tan TL, Maltenfort MG, Chen AF, Shahi A, Higuera CA, Siqueira M, Parvizi J. Development and Evaluation of a Preoperative Risk Calculator for Periprosthetic Joint Infection Following Total Joint Arthroplasty. J Bone Joint Surg Am 2018; 100:777-785. [PMID: 29715226 DOI: 10.2106/jbjs.16.01435] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Preoperative identification of patients at risk for periprosthetic joint infection (PJI) following total hip arthroplasty (THA) or total knee arthroplasty (TKA) is important for patient optimization and targeted prevention. The purpose of this study was to create a preoperative PJI risk calculator for assessing a patient's individual risk of developing (1) any PJI, (2) PJI caused by Staphylococcus aureus, and (3) PJI caused by antibiotic-resistant organisms. METHODS A retrospective review was performed of 27,717 patients (12,086 TKAs and 31,167 THAs), including 1,035 with confirmed PJI, who were treated at a single institution from 2000 to 2014. A total of 42 risk factors, including patient characteristics and surgical variables, were evaluated with a multivariate analysis in which coefficients were scaled to produce integer scores. External validation was performed with use of data on 29,252 patients who had undergone total joint arthroplasty (TJA) at an independent institution. RESULTS Of the 42 risk factors studied, 25 were found not to be significant risk factors for PJI. The most influential of the remaining 17 included a previous open surgical procedure, drug abuse, a revision procedure, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). The areas under the curves were 0.83 and 0.84 for any PJI, 0.86 and 0.83 for antibiotic-resistant PJI, and 0.86 and 0.73 for S. aureus PJI in the internal and external validation models, respectively. The rates of PJI were 0.56% and 0.61% in the lowest decile of risk scores and 15.85% and 20.63% in the highest decile. CONCLUSIONS In this large-cohort study, we were able to identify and validate risk factors and their relative weights for predicting PJI. Factors such as prior surgical procedures and high-risk comorbidities should be considered when determining whether TJA is indicated and when counseling patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Marcelo Siqueira
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Triantafyllopoulos GK, Soranoglou VG, Memtsoudis SG, Sculco TP, Poultsides LA. Rate and Risk Factors for Periprosthetic Joint Infection Among 36,494 Primary Total Hip Arthroplasties. J Arthroplasty 2018; 33:1166-1170. [PMID: 29248486 DOI: 10.1016/j.arth.2017.11.040] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/12/2017] [Accepted: 11/16/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As periprosthetic joint infections (PJIs) can have tremendous health and socioeconomic implications, recognizing patients at risk before surgery is of great importance. Therefore, we sought to determine the rate of and risk factors for deep PJI in patients undergoing primary total hip arthroplasty (THA). METHODS Clinical characteristics of patients treated with primary THA between January 1999 and December 2013 were retrospectively reviewed. These included patient demographics, comorbidities (including the Charlson/Deyo comorbidity index), length of stay, primary diagnosis, total/allogeneic transfusion rate, and in-hospital complications, which were grouped into local and systemic (minor and major). We determined the overall deep PJI rate, as well as the rates for early-onset (occurring within 2 years after index surgery) and late-onset PJI (occurring more than 2 years after surgery). A Cox proportional hazards regression model was constructed to identify risk factors for developing deep PJI. Significance level was set at 0.05. RESULTS A deep PJI developed in 154 of 36,494 primary THAs (0.4%) during the study period. Early onset PJI was found in 122 patients (0.3%), whereas late PJI occurred in 32 patients (0.1%). Obesity, coronary artery disease, and pulmonary hypertension were identified as independent risk factors for deep PJI after primary THA. CONCLUSION The rate of deep PJIs of the hip is relatively low, with the majority occurring within 2 years after THA. If the optimization of modifiable risk factors before THA can reduce the rate of this complication remains unknown, but should be attempted as part of good practice.
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Affiliation(s)
- Georgios K Triantafyllopoulos
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Vasileios G Soranoglou
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Thomas P Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Lazaros A Poultsides
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
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Brown BD, Steinert JN, Stelzer JW, Yoon RS, Langford JR, Koval KJ. Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis. Injury 2017; 48:2705-2708. [PMID: 28988807 DOI: 10.1016/j.injury.2017.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/05/2017] [Accepted: 09/28/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. MATERIALS AND METHODS Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. RESULTS 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017). CONCLUSIONS Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.
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Affiliation(s)
- Bryan D Brown
- Department of Orthopedics, Orlando Regional Medical Center, United States
| | - Justin N Steinert
- Department of Orthopedics, Orlando Regional Medical Center, United States
| | - John W Stelzer
- Department of Orthopedics, Orlando Regional Medical Center, United States
| | - Richard S Yoon
- Department of Orthopedics, Orlando Regional Medical Center, United States.
| | - Joshua R Langford
- Department of Orthopedics, Orlando Regional Medical Center, United States
| | - Kenneth J Koval
- Department of Orthopedics, Orlando Regional Medical Center, United States
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Schwartz FH, Lange J. Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature. Curr Rev Musculoskelet Med 2017; 10:346-355. [PMID: 28664450 DOI: 10.1007/s12178-017-9421-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW It is well established that certain patient-specific risk factors affect outcomes following total joint arthroplasty. The goal of this paper is to summarize the latest data on several variables that have been investigated in the last 3 years and to characterize the effects these factors have on the success of hip and knee replacement. RECENT FINDINGS Preoperative diagnoses of depression and anxiety, liver disease, hypoalbuminemia, vitamin D deficiency, and diabetes mellitus are associated with increased risk of postoperative complications and can lead to worse outcomes after joint replacement surgery. Recent investigations have clearly established a link between these patient-specific factors and poor outcomes after hip and knee arthroplasty, but future research is needed to determine best practices for stratifying and mitigating these risks for patients.
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Affiliation(s)
- Forrest H Schwartz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jeffrey Lange
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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George DA, Drago L, Scarponi S, Gallazzi E, Haddad FS, Romano CL. Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification. World J Orthop 2017; 8:400-411. [PMID: 28567344 PMCID: PMC5434347 DOI: 10.5312/wjo.v8.i5.400] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/05/2017] [Accepted: 03/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections (PJI). METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017). CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.
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Tan TL, Gomez MM, Kheir MM, Maltenfort MG, Chen AF. Should Preoperative Antibiotics Be Tailored According to Patient's Comorbidities and Susceptibility to Organisms? J Arthroplasty 2017; 32:1089-1094.e3. [PMID: 28040397 DOI: 10.1016/j.arth.2016.11.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/11/2016] [Accepted: 11/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty patients regardless of their medical conditions or immune status; however, no studies have evaluated the individualizing of antibiotics. The aims of this study were (1) to determine if comorbidities influence the organism profile of PJIs, and (2) to investigate if the efficacy of two different perioperative antibiotics (cefazolin or vancomycin) for preventing PJI is affected by patient's comorbidities. METHODS Using an institutional database of 1022 PJIs, the influence of different patient's comorbidities on the organism profile was evaluated. To investigate the influence of perioperative antibiotics (cefazolin or vancomycin monotherapy) on PJI rate, 8575 primary total joint arthroplasties were identified, crossmatched for PJI, and analyzed based on the comorbidities of the cohort. The PJI rate of each antibiotic within each comorbidity was compared. RESULTS Although no comorbidities were associated with an increased rate of Gram-positive infections or Gram-negative infections, metastatic disease (odds ratio [OR] 5.71, P = .018), congestive heart failure (OR 2.2, P = .010), chronic pulmonary disease (OR 1.76, P = .015), and diabetes mellitus (OR 1.66, P = .019) were associated with antibiotic resistant organisms. However, there was no difference in the PJI rate between cefazolin and vancomycin monotherapy when stratifying for diabetes mellitus, rheumatoid arthritis, liver disease, and hypothyroidism. CONCLUSION The results of the present study support the current recommendations of a universal antibiotic prophylaxis protocol rather than an antibiotic regimen individualized to a patient's comorbidities.
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Affiliation(s)
- Timothy L Tan
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Miguel M Gomez
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael M Kheir
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Newman JM, Schiltz NK, Mudd CD, Szubski CR, Klika AK, Barsoum WK. Impact of Cirrhosis on Resource Use and Inpatient Complications in Patients Undergoing Total Knee and Hip Arthroplasty. J Arthroplasty 2016; 31:2395-2401. [PMID: 27236746 PMCID: PMC5069119 DOI: 10.1016/j.arth.2016.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cirrhosis is a major cause of morbidity and mortality and is an important risk factor for complications in surgical patients. The purpose of this study was to investigate the association of cirrhosis with postoperative complications, length of stay (LOS), and costs among patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS Using the Nationwide Inpatient Sample between 2000 and 2011, we identified patients who had a primary TKA or primary THA. TKA patients were divided into 2 groups: (1) cirrhosis (n = 41,464) and (2) no cirrhosis (n = 5,721,297) and THA patients were divided into 2 groups: (1) cirrhosis (n = 27,401) and (2) no cirrhosis (n = 2,622,539). Patient demographics, comorbidities, perioperative complications, LOS, and incremental costs were analyzed. An additional subgroup analysis by cirrhosis etiology was performed. RESULTS Multivariable analysis revealed cirrhosis was associated with 1.55 (95% confidence interval: 1.47-1.63) times higher odds of any complication after TKA and 1.59 (1.50-1.69) higher odds after THA. Adjusted outcomes showed cirrhotic TKA patients had $1857 higher costs and 0.30 days longer LOS and THA cirrhotic patients had $1497 higher costs and 0.48 longer LOS. We found similar results for each cirrhosis subtype but alcohol-related had the highest resource use and complication rate. CONCLUSION Patients with cirrhosis who are undergoing TKA or THA are at a significantly increased risk for perioperative complications, increased LOS, and higher costs. The perioperative complications and costs were highest among patients with alcohol-related cirrhosis.
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Affiliation(s)
- Jared M. Newman
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Nicholas K. Schiltz
- Department of Epidemiology and Biostatistics, Case Western Reserve University, 2103 Cornell Rd. Cleveland, OH 44106
| | - Christopher D. Mudd
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Caleb R. Szubski
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195
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