Wendy M. Novicoff

Evaluating comorbidities in total hip and knee arthroplasty: available instruments.

Each year millions of patients are treated for joint pain with total joint arthroplasty, and the numbers are expected to rise. Comorbid disease is known to influence the outcome of total joint arthroplasty, and its documentation is therefore of utmost importance in clinical evaluation of the individual patient as well as in research. In this paper, we examine the various methods for obtaining and assessing comorbidity information for patients undergoing joint replacement. Multiple instruments are reliable and validated for this purpose, such as the Charlson Index, Index of Coexistent Disease, and the Functional Comorbidity Index. In orthopedic studies, the Charnley classification and the American Society of Anesthesiologists physical function score (ASA) are widely used. We recommend that a well-documented comorbidity index that incorporates some aspect of mental health is used along with other appropriate instruments to objectively assess the preoperative status of the patient.

Transfusion Rates Are Increasing Following Total Hip Arthroplasty: Risk Factors and Outcomes

Despite attempts to minimize exposure to allogeneic blood, there are little data on recent nationwide trends in transfusion following total hip arthroplasty (THA) and no consensus on indications. The purpose of this study was to examine the rate, predictors, and inpatient outcomes associated with transfusion after primary THA. This retrospective cohort study analyzed the data collected from US Nationwide Inpatient Sample (NIS) for each year during the period 2005-2008 to assess the trends in transfusion in patients who underwent elective primary THA. Logistic regression models were used to evaluate the predictive risk factors for blood transfusion. The University Hospital Consortium (UHC) database was also queried to examine the variability in rates of transfusion at different academic medical centers. A total of 129,901 patients were identified in the NIS database. The transfusion rates following THA consistently increased from 18.12% in 2005 to 21.21% in 2008 (P<0.0001). Hospitals in the Northeast and Midwest region had the highest and lowest rates of transfusion, respectively. Significant risk factors for blood transfusion were female gender (odds ratio, OR 2.1), age above 85 (OR 2.9), African-American race (OR 1.7), Medicare payor status (OR 1.6), being at a hospital in the Northeast Region (OR 1.4), the presence of preoperative anemia (OR 1.6), having at least one comorbidity (OR 1.3), and a high Charlson Index score (OR 2.2). Patients receiving blood transfusions had increased in-hospital mortality, longer lengths of stay, and higher total charges compared to non-transfused patients (P<0.001). The UHC database demonstrated that transfusion rates vary widely across different institutions from <5% to >80%. The incidence of blood transfusion has recently increased following total hip arthroplasty and there is great variability in practice. We identified several patient risk factors along with the morbidity and mortality independently associated with transfusion following THA. Further work is needed to standardize the approach to blood conservation and minimize exposure to allogenic blood.

Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study.

The purpose of this study was to assess the incidence of the diagnosis of depression and determine the impact of this diagnosis on early postoperative outcomes following total joint arthroplasty (TJA). Multivariate analysis of the Nationwide Inpatient Sample database was used to compare the association of depression with inhospital morbidity, mortality, length of stay, and hospital charges following TJA. The rate of diagnosis of depression in the arthroplasty population was 10.0%. Patients with depression were significantly more likely to be white, female, and have Medicaid as a primary payer (all P<0.05). Depression was associated with a greater risk of post-operative psychosis (OR = 1.74), anemia (OR = 1.14), infection (OR = 1.33), and pulmonary embolism (OR 1.20), and a lower risk of cardiac (OR = 0.93) and gastrointestinal complications (OR = 0.80). Depression was not associated with in-hospital mortality. Depression appears to impact early postoperative morbidity after TJA, a finding which is important for patient counseling and risk adjustment.

American Society of Anesthesiologist Physical Status Score May Be Used as a Comorbidity Index in Hip Fracture Surgery

Comorbidities affect outcome, but there is no consensus which comorbidity instrument is best in orthopedic surgery. We assessed whether the American Society of Anesthesiologists Physical Status score (ASA) predicts long-term mortality after hip fracture. We followed 1635 patients for 5 to 10 years after operative treatment of hip fracture. Unadjusted Kaplan-Meyer statistics indicated that the overall survival of the patients was 4.7 (95% confidence interval [CI], 4.5-4.9) years, but survival varied significantly between the ASA groups. Survival for ASA 1 was 8.5 years (95% CI, 7.8-9.2); for ASA 2, it was 5.6 years (95% CI, 5.3-5.9); for ASA 3, it was 3.5 years (95% CI, 3.2-3.7); and for ASA 4, survival was 1.6 years (95% CI, 1.0-2.1). The ASA predicts long-term mortality after hip fracture treatment.

Medicaid payer status is associated with in-hospital morbidity and resource utilization following primary total joint arthroplasty.

BACKGROUND Previous reports suggest that there are major disparities in outcomes following total joint arthroplasty among patients with different payer statuses. The explanation for these differences is largely unknown and may result from confounding variables. The Affordable Care Act expansion of Medicaid coverage in 2014 makes the examination of these disparities particularly relevant. METHODS The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database was used to identify patients who had undergone primary hip or knee arthroplasty from 2002 through 2011. Complications, costs, and length of hospital stay for patients with Medicaid were compared with those for non-Medicaid patients. Each Medicaid patient was matched to a non-Medicaid patient according to age, sex, race, type of total joint arthroplasty, procedure year, hospital characteristics, smoking status, and all twenty-nine comorbidities defined in the NIS-modified Elixhauser comorbidity measure. RESULTS It was determined that 191,911 patients who underwent total joint arthroplasty had Medicaid payer status (2.8% of the entire total joint arthroplasty population), and 107,335 (56%) of these Medicaid patients were matched one to one to a non-Medicaid patient for all variables for the adjusted analysis. After matching, Medicaid patients were found to have a higher prevalence of postoperative in-hospital infection (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3 to 2.1), wound dehiscence (OR, 2.2; 95% CI, 1.4 to 3.4), and hematoma or seroma (OR, 1.3; 95% CI, 1.2 to 1.4) but a lower risk of cardiac complications (OR, 0.7; CI, 0.6 to 0.9). The length of the hospital stay was longer, total cost was higher, and discharge to an inpatient facility was more frequent for patients with Medicaid status (p < 0.01). CONCLUSIONS Compared with non-Medicaid patients, Medicaid patients have a significantly higher risk for certain postoperative in-hospital complications and consume more resources following total joint arthroplasty even when the two groups have been matched for patient-related factors and comorbid conditions commonly associated with low socioeconomic status. Additional work is needed to understand the complex interplay between socioeconomic status and outcomes, to ensure appropriate resources are allocated to maintain access for this patient population, and to develop appropriate risk stratification.

Critical analysis of the evidence for current technologies in bone-healing and repair.

Substances that enhance fracture-healing and bone regeneration have valuable clinical application and merit future research. Advances in these technologies will enhance our ability to heal fractures in a more effective and expedient manner. This review provides a brief description of the different techniques and technologies and their respective clinical utility. This paper also reviews the available literature on gene therapy, tissue engineering, growth factors, osteoconductive agents, and physical forces and assesses the evidence regarding the current status of these techniques of healing and regenerating bone. Only twenty-seven articles met our guidelines for studies containing Level-I evidence. We were able to determine that atrophic nonunions and pseudarthrosis led to poorer outcomes, and the results were uniformly poor irrespective of the technique used. Although the literature contains a large number of studies on the effects of different agents and modalities on bone repair and healing, it still is not clear how these agents work or in what circumstances they should be used. Many of the treatment modalities of interest are still at an experimental stage, so good evidence to support clinical practice is lacking. Additional multicenter, prospective randomized studies are needed to define the indications, specifications, dosage, limitations, and contraindications in the treatment of nonunions. Studies are also needed to address the full clinical feasibility of the role of each modality in fracture-healing and repair.

Morbid obesity in total shoulder arthroplasty: risk, outcomes, and cost analysis

BACKGROUND A rate of obesity in the US population and the rate of total shoulder arthroplasty (TSA) has increased over the past decade. Little information exists concerning the number of morbidly obese patients undergoing TSA or how these patients compare with their non-obese counterparts. The goal of this study was to determine whether morbidly obese patients exhibit greater rates of postoperative in-hospital complications, mortality, or utilization of resources. METHODS We used the Nationwide Inpatient Sample to analyze 31,924 patients undergoing TSA between 1998 and 2008. Multivariate analysis with logistic regression modeling was used to compare patients based on body mass index for various outcomes. RESULTS Among morbidly obese patients, predictors of death included age (odds ratio, 1.06; 95% confidence interval, 1.01-1.11) and Deyo score. A comparison of hospital costs among patients showed that increased patient body mass index led to increased hospital charges independent of physician charges (

Mandated Venous Thromboembolism Prophylaxis

38,103.88 in morbidly obese patients vs

Age as an Independent Risk Factor for Postoperative Morbidity and Mortality After Total Joint Arthroplasty in Patients 90 Years of Age or Older

33,521.66 in non-obese patients, P = .0001). An increased length of stay was observed in morbidly obese patients (2.84 days vs 2.52 days in obese patients and 2.56 days in non-obese patients, P = .003). Respiratory dysfunction occurred more commonly in morbidly obese patients than in non-obese patients (1.2% vs 0.7%; odds ratio, 1.61; P < .01). CONCLUSIONS Obese patients tend to have longer hospital stays, an increased risk of postoperative respiratory complications, and higher costs. Although there was a trend toward an increased early postoperative mortality rate, obesity was not associated with an increased incidence of most complications. These findings should be supplemented with further research to assist patient counseling and risk adjustment for obese patients undergoing TSA.

Surgical Simulators and Hip Fractures: A Role in Residency Training?

The purpose of this study was to assess the prevalence and seriousness of adverse outcomes owing to mandatory venous thromboembolism (VTE) prophylaxis. A retrospective study of administrative claims data was conducted to look at the rate of VTEs and other complications in patients undergoing hip and knee arthroplasty. Additional analysis was done to determine whether patient characteristics could explain findings. Although rates of VTE remain unchanged from 2003 to 2007, the rate of immediate postprocedure hematoma, seroma, and hemorrhage went from 1.4% in 2003 to 9.6% in 2006. Return to a more conservative prophylaxis approach resulted in a marked decrease in rates of significant bleeding events. Although preventing VTEs is an important quality concern, mandating prophylaxis for all patients could have unintended adverse outcomes. These guidelines might need to be reevaluated for hip and knee arthroplasty patients.