Lazaros A. Poultsides

Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998-2008.

BACKGROUND:The use of total joint arthroplasties is increasing worldwide. In this work we aim to elucidate recent trends in demographics and perioperative outcomes of patients undergoing total hip (THA) or total knee arthroplasty (TKA). METHODS:Data from the US Nationwide Impatient Sample between 1998 and 2008 were gathered for primary THAs and TKAs. Trends in patient age, comorbidity burden, length of hospitalization, frequency of major perioperative complications, and in-hospital mortality were analyzed. In-hospital outcomes were reported as events per 1000 inpatient days to account for changes in length of hospitalization over time. Deyo index, discharge status, and the interaction effect of time and discharge status were included in the adjusted trend analysis for morbidity. RESULTS:Between 1998 and 2008, the average age of patients undergoing TKA and THA decreased by 2 to 3 years (P < 0.001). The average length of stay decreased by approximately 1 day over the time interval studied (P < 0.001). The percentage of patients being discharged home declined from 29.7% to 25.4% after TKA and from 29.3% to 24.2% after THA, in favor of dispositions to long- and short-term care facilities (P < 0.0001). Comorbidity burden as measured by the Deyo comorbidity index increased by 35% and 30% for TKA and THA patients, respectively (P < 0.0001). After TKA, there was an increase in the incidence of the following major complications: pulmonary embolism (coefficient estimate [CE] 0.069; 95% confidence interval [CI], 0.059–0.079; P < 0.0001), sepsis (CE 0.034; 95% CI, 0.014–0.054; P = 0.001), nonmyocardial infarction cardiac complications (CE 0.038; 95% CI, 0.035–0.041; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.031–0.047; P < 0.0001). After THA, there was an increase in the incidence of the following major complications: pulmonary embolism (CE 0.031; 95% CI, 0.012–0.049; P = 0.001), sepsis (CE 0.060; 95% CI, 0.039–0.081; P < 0.0001), nonmyocardial infarction cardiac complications (CE 0.040; 95% CI, 0.036–0.043; P < 0.0001), and pneumonia (CE 0.039; 95% CI, 0.029–0.048). In-hospital mortality declined after both TKA (CE −0.059; 95% CI, −0.077 to −0.040; P < 0.0001) and THA (CE −0.068; 95% CI, −0.086 to −0.051; P < 0.0001). CONCLUSION:Between 1998 and 2008, trends show increases in several major in-hospital complications after THA and TKA, including pulmonary embolism, sepsis, nonmyocardial infarction cardiac complications, and pneumonia. Despite the increase in complications, declining in-hospital mortality was noted over this period.

Anterior Inferior Iliac Spine Morphology Correlates With Hip Range of Motion: A Classification System and Dynamic Model

BackgroundThe anterior inferior iliac spine (AIIS) contributes to hip dysfunction in patients with symptomatic impingement and resection of a prominent AIIS can reportedly improve function. However, the variability of the AIIS morphology and whether that variability correlates with risk of associated symptomatic impingement are unclear.Questions/purposesWe characterized AIIS morphology in patients with hip impingement and tested the association between specific AIIS variants and hip range of motion.MethodsWe evaluated three-dimensional CT reconstructions of 53 hips (53 patients) with impingement and defined three morphological AIIS variants: Type I when there was a smooth ilium wall between the AIIS and the acetabular rim, Type II when the AIIS extended to the level of the rim, and Type III when the AIIS extended distally to the acetabular rim. A separate cohort of 78 hips (78 patients) with impingement was used to compare hip range of motion among the three AIIS types.ResultsMean hip flexion was limited to 120°, 107°, and 93° in hips with Type I, Type II, and Type III AIIS, respectively. Mean internal rotation was limited to 21°, 11°, and 8° in hips with Type I, Type II, and Type III AIIS, respectively.ConclusionsWhen the AIIS is classified into three variants based on the relationship between the AIIS and the acetabular rim in patients with impingement, Type II and III variants are associated with a decrease in hip flexion and internal rotation, supporting the rationale for considering AIIS decompression for variants that extend to and below the rim.Level of EvidenceLevel III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

A cross-sectional survey on prevalence and risk factors for persistent postsurgical pain 1 year after total hip and knee replacement.

Background and Objectives There is a paucity of large multi-institutional surveys to determine the prevalence of and risk factors for persistent pain after total hip (THR) and knee (TKR) replacements. We surveyed a variety of practices and patients and also correlated persistent pain with health-related quality-of-life outcomes. Methods From October 10, 2007, to March 15, 2010, patients who had undergone primary THR or TKR with a minimum follow-up of 1 year were identified. A previously published questionnaire to identify persistent postsurgical pain that included a 36-item Short Form Health Survey was mailed to this group. Independent risk factors for persistent pain were identified with logistic regression. Results Responses from 1030 patients who underwent surgery at some point in time between June 13, 2006, and June 24, 2009, were analyzed (32% response rate). Forty-six percent of patients reported persistent pain (38% after THR and 53% after TKR) with a median average pain score of 3 of 10 and worst pain score of 5. Independent risk factors for persistent pain were female sex (odds ratio [OR], 1.23), younger age (OR, 0.97), prior surgery on hip or knee (OR, 1.39), knee versus hip replacement (OR, 1.65), lower-quality postsurgical pain control (OR, 0.9), and presence of pain in other areas of the body (OR, 2.09). All scores in the 36-item Short Form Health Survey were worse (8%–28% decrease) in patients with persistent postsurgical pain (P < 0.001). Conclusions Persistent postsurgical pain is common after THR and TKR and is associated with reduced health-related quality of life, although our survey may be biased by the low response rate and retrospective recall bias. Nonmodifiable risk factors may lead to risk stratification. Severity of acute postoperative pain may be a modifiable risk factor.

In-hospital surgical site infections after primary hip and knee arthroplasty--incidence and risk factors.

Data of hospitalizations for THA or TKA were analyzed for each year between 1998 and 2007 from the National Inpatient Sample. Demographics, comorbidities, incidence of morbidity and mortality, length of hospital stay (LOS), and overall cost were compared for infected and non-infected patients. Perioperative SSI rates were 0.36% for THA and 0.31% for TKA (412,356 and 784,335 patient entries, respectively). Patients with SSI had a significantly higher overall comorbidity burden, higher perioperative mortality rates, longer length of stay, and higher complication rates. Average cost of in-hospital care was double for SSI versus non-SSI patients. Independent risk factors for perioperative SSI included male gender, minority race, a diagnosis for cancer, liver disease, coagulopathies, fluid and electrolyte disorders, congestive heart failure, and pulmonary circulatory disease. Data relied on coded information and could not differentiate between superficial or deep infection, or capture patients readmitted for SSI, and therefore may have underestimated the true incidence of SSI.

Novel CT-based Three-dimensional Software Improves the Characterization of Cam Morphology

BackgroundIncomplete correction of femoral offset and sphericity remains the leading cause for revision surgery for symptomatic femoroacetabular impingement (FAI). Because arthroscopic exploration is technically difficult, a detailed preoperative understanding of morphology is of paramount importance for preoperative decision-making.Questions/purposesThe purposes of this study were to (1) characterize the size and location of peak cam deformity with a prototype CT-based software program; (2) compare software alpha angles with those obtained by plain radiograph and CT images; and (3) assess whether differences can be explained by variable measurement locations.MethodsWe retrospectively reviewed the preoperative plain radiographs and CT scans of 100 symptomatic cam lesions treated by arthroscopy; recorded alpha angle and clockface measurement location with a novel prototype CT-based software program, CT, and Dunn lateral plain radiographs; and used ordinary least squares regressions to assess the relationship between alpha angle and measurement location.ResultsThe software determined a mean alpha angle of 70.8° at 1:23 o’clock and identified 60% of maximum alpha angles between 12:45 and 1:45. The CT and plain radiographs underestimated by 5.7° and 8.2°, respectively. The software-based location was anterosuperior to the mean CT and plain radiograph measurement locations by 41 and 97 minutes, respectively. Regression analysis confirmed a correlation between alpha angle differences and variable measurement locations.ConclusionsSoftware-based three-dimensional (3-D) imaging generated alpha angles larger than those found by plain radiograph and CT, and these differences were the result of location of measurement. An automated 3-D assessment that accurately describes the location and topography of FAI may be needed to adequately characterize preoperative deformity.Level of EvidenceLevel III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Comparative perioperative outcomes associated with neuraxial versus general anesthesia for simultaneous bilateral total knee arthroplasty.

Background and Objectives The influence of the type of anesthesia on perioperative outcomes after bilateral total knee arthroplasty (BTKA) remains unknown. Therefore, we examined a large sample of BTKA recipients, hypothesizing that neuraxial anesthesia would favorably impact on outcomes. Methods We identified patient entries indicating elective BTKA between 2006 and 2010 in a national database; subgrouped them by type of anesthesia: general (G), neuraxial (N), or combined neuraxial-general (NG); and analyzed differences in demographics and perioperative outcomes. Results Of 15,687 identified procedures, 6.8% (n = 1066) were performed under N, 80.1% (n = 12,567) under G, and 13.1% (n = 2054) under NG. Comparing N to G and NG, patients in group N were, on average, younger (63.9, 64.6, and 64.8 years; P = 0.030) but did not differ in overall comorbidity burden. Patients in group N required blood product transfusions significantly less frequently (28.5%, 44.7%, 38.0%; P < 0.0001). In-hospital mortality, 30-day mortality, and complication rates tended to be lower in group N, without reaching statistical significance. After adjusting for covariates, N and NG were associated with 16.0% and 6.0% reduction in major complications compared with G, but only the reduced odds for the requirement of blood transfusions associated with N reached statistical significance (N vs G: odds ratio, 0.52 [95% CI, 0.45–0.61], P < 0.0001; NG vs G: odds ratio, 0.77 [95% CI, 0.69–0.86], P < 0.0001). Conclusions Neuraxial anesthesia for BTKA is associated with significantly lower rates of blood transfusions and, by trend, decreased morbidity. Although by itself the effect may be limited, N might be used within a multimodal approach to reduce complications after BTKA.

Demographics and Perioperative Outcome in Patients with Depression and Anxiety Undergoing Total Joint Arthroplasty: A Population-Based Study

BACKGROUND Depression and anxiety are highly prevalent psychiatric disorders. However, little is known about their impact on outcomes in the perioperative setting. This study is intended to gain insight into epidemiology and effects on perioperative morbidity, mortality, length of hospital stay, discharge and cost. METHODS We obtained the National Inpatient Sample from the Hospital Cost and Utilization Project for each year between 2000 and 2008. Entries indicating the performance of primary total hip and knee arthroplasty were identified and separated into four groups: (1) those with concomitant diagnosis of depression or (2) anxiety, (3) both, and (4) none of these diagnoses. The incidence of major complications, non-routine discharge, length, and cost of hospitalization were assessed. Regression analysis was performed to identify if psychiatric comorbidity was an independent risk factor for each outcome. RESULTS We identified 1,212,493 patients undergoing arthroplasty between 2000 and 2008. The prevalence of depression and anxiety significantly increased over time. Patients with either condition had higher hospital charges, rates of non-routine discharges and comorbidity index. Depression or anxiety were associated with significantly decreased adjusted odds for in-hospital mortality (OR = 0.53, p = 0.0147; OR = 0.58, p = 0.0064). The risk of developing a major complication was slightly lower in patients with depression, anxiety or both (OR=0.95, p = 0.0738; OR = 0.95, p = 0.0259; OR = 0.94, p = 0.7349). CONCLUSIONS Patients suffering from depression, anxiety, or both require more healthcare resources in a perioperative setting. However, lower short-term mortality in spite of higher comorbidity burden and without extensive changes in perioperative complication profile indicates better outcome for this group of patients.

Bilateral total knee arthroplasty: risk factors for major morbidity and mortality.

BACKGROUND:Bilateral total knee arthroplasty (BTKA) performed during the same hospitalization carries increased risk for morbidity and mortality compared with the unilateral approach. However, no evidence-based stratifications to identify patients at risk for major morbidity and mortality are available. Our objective was to determine the incidence and patient-related risk factors for major morbidity and mortality among patients undergoing BTKA. METHODS:Nationwide Inpatient Survey data collected for the years 1998 to 2007 were analyzed and cases of elective BTKA procedures were included. Patient demographics, including comorbidities, were analyzed and frequencies of mortality and major complications were computed. Subsequently, a multivariate analysis was conducted to determine independent risk factors for major morbidity and mortality. RESULTS:Included were 42,003 database entries, representing an estimated 206,573 elective BTKAs. The incidence of major in-hospital complications and mortality was 9.5%. Risk factors for adverse outcome included advanced age (odds ratios [ORs] for age groups 65–74 and >75 years were 1.88 [confidence interval, CI: 1.72, 2.05] and 2.66 [CI: 2.42, 2.92], respectively, compared with the 45–65 years group), male gender (OR: 1.54 [CI: 1.44, 1.66]), and a number of comorbidities. The presence of congestive heart failure (OR: 5.55 [CI: 4.81, 6.39]) and pulmonary hypertension (OR: 4.10 [CI: 2.72, 6.10]) were the most significant risk factors associated with increased odds for adverse outcome. CONCLUSIONS:We identified patient-related risk factors for major morbidity and mortality in patients undergoing BTKA. Our data can be used to aid in the selection of patients for this procedure.

Epidemiology and risk factors for perioperative mortality after total hip and knee arthroplasty

The perioperative mortality of total knee and hip arthroplasties (TKA, THA) remains a major concern among health care providers and their patients. The increase in utilization of TKA and THA makes it imperative to be aware of factors that are associated with this unfortunate event. Therefore we analyzed the Nationwide Inpatient Sample data from 1998 to 2008 and compared admissions with perioperative mortality to those that survived their hospitalization. An estimated total of 4,438,213 TKA and 2,182,121 THA procedures were performed in the United States between 1998 and 2008. The average mortality rate for TKA was 0.13% and 0.18% for THA, or 0.34 and 0.44 events per 1,000 inpatient days, respectively. Independent risk factors for in‐hospital mortality were advanced age, male gender, ethnic minority background, emergency admission as well as a number of comorbidities and complications. Furthermore, we demonstrated that the timing of death occurred earlier after TKA when compared to THA, with 50% of fatalities occurring by day 4 versus day 6 of the hospitalization, respectively. This study provides nationally representative information on risk factors for and timing of perioperative mortality after TKA and THA. Our data can be used to assess the risk for perioperative mortality and to develop targeted intervention to decrease such risk.

An algorithmic approach to mechanical hip pain.

BackgroundAs our understanding of hip pathology evolves, the focus is shifting toward earlier identification of hip pathology. Therefore, it is vitally important to elucidate intra-articular versus extra-articular pathology of hip pain in every step of the patient encounter: history, physical examination, and imaging.Questions/PurposesThe objective was to address the following research questions: (1) Can an algorithmic approach to physical examination of a painful non-arthritic hip provide a more accurate diagnosis and improved treatment plan? (2) Does an anatomical layered concept of clinical diagnosis improve diagnostic accuracy? (3) What are the diagnostic tools necessary for the accurate application of a four-layer (osteochondral, inert, contractile, and neuromechanical) diagnosis?MethodsAn unrestricted computerized search of MEDLINE was conducted. Different terms were used in various combinations.ResultsAn algorithmic approach to physical examination of a painful nonarthritic hip, including history, physical examination (specific tests), and advanced imaging allow for better interpretation of debilitating intra- and extra-articular disorders and their effect on core performance. Additionally, it improves our understanding as to how underlying abnormal joint mechanics may predispose the hip joint and the associated hemipelvis to asymmetric loads. These abnormal joint kinematics (layer I) can lead to cartilage and labral injury (layer II), as well as resultant injury to the musculotendinous (layer III) and neural structures (layer IV) about the hip joint and the hemipelvis. The layer concept is a systematic means of determining which structures about the hip are the source of hip pathology and how to best implement treatment.ConclusionsA clear understanding of the differential diagnosis of hip pain through a detailed and systematic physical examination, diagnostic imaging assessment, and the interpretation of how mechanical factors can result in such a wide range of compensatory injury patterns about the hip can facilitate the diagnosis and treatment recommendations.