[Show abstract][Hide abstract] ABSTRACT: Background and purpose - Aseptic revisions comprise 80% of revision total knee arthroplasties (TKAs). We determined the incidence of re-revision TKA, the reasons for re-revision, and risk factors associated with these procedures. Patients and methods - We conducted a retrospective cohort study of 1,154 patients who underwent aseptic revision TKA between 2002 and 2013 and were followed prospectively by a total joint replacement registry in the USA. Revision was defined as any operation in which an implanted component was replaced. Patient-, surgeon-, and procedure-related risk factors were evaluated. Survival analyses were conducted. Results - There were 114 re-revisions (10%) with a median time to reoperation of 3.6 years (interquartile range (IQR): 2.6-5.2). The infection rate was 2.9% (34/1,154) and accounted for 30% of re-revisions (34 of 114). In adjusted models, use of antibiotic-loaded cement was associated with a 50% lower risk of all-cause re-revision surgery (hazard ratio (HR) = 0.5, 95% CI: 0.3-0.9), age with a 20% lower risk for every 10-year increase (HR = 0.8, CI: 0.7-1.0), body mass index (BMI) with a 20% lower risk for every 5-unit increase (HR = 0.8, CI: 0.7-1.0), and a surgeon's greater cumulative experience (≥ 20 cases vs. < 20 cases) with a 3 times higher risk of re-revision (HR = 2.8, CI: 1.5-5). Interpretation - Revised TKAs were at high risk of subsequent failure. The use of antibiotic-loaded cement, higher age, and higher BMI were associated with lower risk of further revision whereas a higher degree of surgeon experience was associated with higher risk.
[Show abstract][Hide abstract] ABSTRACT: Total hip arthroplasty (THA) is often performed in patients who are older and may take bisphosphonates to treat a variety of conditions, most commonly osteoporosis. However, the clinical effects of bisphosphonate use on patients who have undergone THA are not well described.
(1) Is bisphosphonate use in patients with osteoarthritis undergoing primary THA associated with a change in the risk of all-cause revision, aseptic revision, or periprosthetic fracture compared with patients not treated with bisphosphonates? (2) Does the risk of bisphosphonate use and revision and periprosthetic fracture vary by patient bone mineral density and age?
A retrospective cohort study of 12,878 THA recipients for the diagnosis of osteoarthritis was conducted; 17.8% of patients were bisphosphonate users. Data sources for this study included a joint replacement registry (93% voluntary participation) and electronic health records and an osteoporosis screening database with complete capture of cases as part of the Kaiser Permanente integrated healthcare system. The endpoints for this study were revision surgery for any cause, aseptic revision, and periprosthetic fracture. The exposure of interest was bisphosphonate use; patients were considered users if prescriptions were continuously refilled for a period equal to or longer than 6 months. Bone quality (based on dual-energy x-ray absorptiometery ordered based on the National Osteoporosis Foundation's clinical guidelines taken within 5 years of the THA) and patient age (< 65 versus ≥ 65 years) were evaluated as effect modifiers. Patient, surgeon, and hospital factors were evaluated as confounders. Cox proportional hazards models were used. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined.
Age- and sex-adjusted risks of all-cause (HR, 0.50; 95% CI, 0.33-0.74; p < 0.001) and aseptic revision (HR, 0.53; 95% CI, 0.34-0.81; p = 0.004) was lower in bisphosphonate users than in nonusers. The adjusted risk of periprosthetic fractures in patients on bisphosphonates was higher than in patients not on bisphosphonates (HR, 1.92; 95% CI, 1.13-3.27; p = 0.016). Lower risks of all-cause revision and aseptic revision were observed in patients with osteopenia (HR, 0.49; 95% CI, 0.29-0.84; and HR, 0.53; 95% CI, 0.29-0.99, respectively) and osteoporosis (HR, 0.22; 95% CI, 0.08-0.62; and HR, 0.33; 95% CI, 0.11-0.99, respectively).
Patients considered bisphosphonate users who underwent THA had a lower risk for revision surgery. Bisphosphonate use was associated with a higher risk of periprosthetic fractures in younger patients with normal bone quantity. Evaluation of bone quality and bisphosphonate use for the diagnosis of osteoporosis is encouraged in patients with osteoarthritis who are candidates for primary THA. Further research is required to determine the optimal duration of therapy because long-term bisphosphonate use has been associated with atypical femur fractures.
Level III, therapeutic study.
Clinical Orthopaedics and Related Research 04/2015; 473(11). DOI:10.1007/s11999-015-4263-4 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although total hip arthroplasty (THA) is a successful procedure, 4% to 11% of patients who undergo THA are readmitted to the hospital. Prior studies have reported rates and risk factors of THA readmission but have been limited to single-center samples, administrative claims data, or Medicare patients. As a result, hospital readmission risk factors for a large proportion of patients undergoing THA are not fully understood.
(1) What is the incidence of hospital readmissions after primary THA and the reasons for readmission? (2) What are the risk factors for hospital readmissions in a large, integrated healthcare system using current perioperative care protocols?
The Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) was used to identify all patients with primary unilateral THAs registered between January 1, 2009, and December 31, 2011. The KPTJRR's voluntary participation is 95%. A logistic regression model was used to study the relationship of risk factors (including patient, clinical, and system-related) and the likelihood of 30-day readmission. Readmissions were identified using electronic health and claims records to capture readmissions within and outside the system. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Of the 12,030 patients undergoing primary THAs included in the study, 59% (n = 7093) were women and average patient age was 66.5 years (± 10.7).
There were 436 (3.6%) patients with hospital readmissions within 30 days of the index procedure. The most common reasons for readmission were infection and inflammatory reaction resulting from internal joint prosthetic (International Classification of Diseases, 9(th) Revision, Clinical Modification [ICD-9-CM] 996.66, 7.0%); other postoperative infection (ICD-9-CM 998:59, 5.5%); unspecified septicemia (ICD-9-CM 038.9, 4.9%); and dislocation of a prosthetic joint (ICD-9-CM 996.42, 4.7%). In adjusted models, the following factors were associated with an increased likelihood of 30-day readmission: medical complications (OR, 2.80; 95% CI, 1.59-4.93); discharge to facilities other than home (OR, 1.89; 95% CI, 1.39-2.58); length of stay of 5 or more days (OR, 1.80; 95% CI, 1.22-2.65) versus 3 days; morbid obesity (OR, 1.74; 95% CI, 1.25-2.43); surgeries performed by high-volume surgeons compared with medium volume (OR, 1.53; 95% CI, 1.14-2.08); procedures at lower-volume (OR, 1.41; 95% CI, 1.07-1.85) and medium-volume hospitals (OR, 1.81; 95% CI, 1.20-2.72) compared with high-volume ones; sex (men: OR, 1.51; 95% CI, 1.18-1.92); obesity (OR, 1.32; 95% CI, 1.02-1.72); race (black: OR, 1.26; 95% CI, 1.02-1.57); increasing age (OR, 1.03; 95% CI, 1.01-1.04); and certain comorbidities (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, and psychoses).
The 30-day hospital readmission rate after primary THA was 3.6%. Modifiable factors, including obesity, comorbidities, medical complications, and system-related factors (hospital), have the potential to be addressed by improving the health of patients before this elective procedure, patient and family education and planning, and with the development of high-volume centers of excellence. Nonmodifiable factors such as age, sex, and race can be used to establish patient and family expectations regarding risk of readmission after THA. Contrary to other studies and the finding of increased hospital volume associated with lower risk of readmission, higher volume surgeons had a higher risk of patient readmission, which may be attributable to the referral patterns in our organization.
Level III, therapeutic study.
Clinical Orthopaedics and Related Research 04/2015; 473(11). DOI:10.1007/s11999-015-4278-x · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined the assumption that patients undergoing same-day bilateral total knee arthroplasty (TKA) have a higher incidence of major peri-operative complications than patients who stage their procedures over the course of a year. Between April 2001 and March 2007, prospective data were collected using a total joint registry. Patients undergoing primary, bilateral, same-day, TKAs were compared to patients undergoing primary, staged, bilateral TKAs within 12 months of the index operation. A total of 2441 TKAs were performed on the same day, while 4231 were staged. There were no significant differences in 90-day mortality, thrombotic events and infections between the two groups. Performing same-day bilateral TKA does not predispose patients to increased cumulative incidence of major complications over staged arthroplasty.
The Journal of arthroplasty 12/2013; 29(4). DOI:10.1016/j.arth.2012.09.009 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The reported revision rates for cemented unicompartmental knee arthroplasties have varied widely. The effect of implant selection, patient characteristics, and surgeon characteristics on revision risk has not been evaluated fully. The purpose of the present study was to determine the impact of these variables on the risk for aseptic revision arthroplasty.
We identified all cemented primary unicompartmental knee arthroplasties performed in our health-care system from 2002 to 2009 (median follow-up time = 2.6 years) to assess the risk for aseptic revision. A multivariate marginal Cox proportional-hazards model with robust standard errors (to adjust for the nesting of surgical cases within surgeons) was used to calculate the differential risk for revision of implants after adjusting for surgeon and hospital volume of unicompartmental knee arthroplasties performed; surgeon experience with unicompartmental knee arthroplasties at the time of surgery; surgeon fellowship training; and patient age, sex, weight, body mass index, and American Society of Anesthesiologists (ASA) score.
A total of 1746 unicompartmental knee arthroplasties were identified. The overall revision rate during the study period was 4.98% (95% confidence interval [CI], 4.0% to 6.1%). In a multivariate Cox model, the hazard ratio (HR) for aseptic revision relative to a modern, fixed, metal-backed tibial bearing was significantly higher for an all-polyethylene tibial tray (HR = 3.85, 95% CI = 1.54 to 9.63, p = 0.004) but not significantly higher for a mobile-bearing implant (HR = 2.42, 95% CI = 0.55 to 10.65, p = 0.242) or an older-design, fixed, metal-backed bearing (HR = 1.89, 95% CI = 0.67 to 5.33, p = 0.23). Younger age was associated with increased risk (age less than fifty-five years compared with more than sixty-five years: HR = 4.83, 95% CI = 2.60 to 8.96, p < 0.001), and a higher ASA score (≥3 compared with <3 points: HR = 0.54, 95% CI = 0.32 to 0.93, p = 0.027) and a greater mean yearly surgeon volume of unicompartmental knee arthroplasties (twelve or fewer compared with more than twelve: HR = 2.18, 95% CI = 1.28 to 3.74, p = 0.004) were associated with reduced risk.
Implant selection can have a considerable effect on the risk for aseptic revision following a cemented unicompartmental knee arthroplasty, as can patient and surgeon factors. Therefore, the variation among risk estimates reported in the literature for unicompartmental knee arthroplasty revision may be explained by differences in patient characteristics and implant selection as well as the surgeons' yearly volume of unicompartmental knee arthroplasties.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
The Journal of Bone and Joint Surgery 12/2013; 95(24):2195-202. DOI:10.2106/JBJS.L.01006 · 5.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the impact of pre-coating the tibial component with polymethylmethacrylate (PMMA) on implant survival in a cohort of 16 548 primary NexGen total knee replacements (TKRs) in 14 113 patients. In 13 835 TKRs a pre-coated tray was used while in 2713 TKRs the non-pre-coated version of the same tray was used. All the TKRs were performed between 2001 and 2009 and were cemented. TKRs implanted with a pre-coated tibial component had a lower cumulative survival than those with a non-pre-coated tibial component (p = 0.01). After adjusting for diagnosis, age, gender, body mass index, American Society of Anesthesiologists grade, femoral coupling design, surgeon volume and hospital volume, pre-coating was an independent risk factor for all-cause aseptic revision (hazard ratio 2.75, p = 0.006). Revision for aseptic loosening was uncommon for both pre-coated and non-pre-coated trays (rates of 0.12% and 0%, respectively). Pre-coating with PMMA does not appear to be protective of revision for this tibial tray design at short-term follow-up. Cite this article: Bone Joint J 2013;95-B:367-70.
Bone and Joint Journal 03/2013; 95-B(3):367-70. DOI:10.1302/0301-620X.95B3.27585 · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Poor glycemic control in patients with diabetes may be associated with adverse surgical outcomes. We sought to determine the association of diabetes status and preoperative glycemic control with several surgical outcomes, including revision arthroplasty and deep infection.
We conducted a retrospective cohort study in five regions of a large integrated health-care organization. Eligible subjects, identified from the Kaiser Permanente Total Joint Replacement Registry, underwent an elective first primary total knee arthroplasty during 2001 through 2009. Data on demographics, diabetes status, preoperative hemoglobin A1c (HbA1c) level, and comorbid conditions were obtained from electronic medical records. Subjects were classified as nondiabetic, diabetic with HbA1c < 7% (controlled diabetes), or diabetic with HbA1c ≥ 7% (uncontrolled diabetes). Outcomes were deep venous thrombosis or pulmonary embolism within ninety days after surgery and revision surgery, deep infection, incident myocardial infarction, and all-cause rehospitalization within one year after surgery. Patients without diabetes were the reference group in all analyses. All models were adjusted for age, sex, body mass index, and Charlson Comorbidity Index.
Of 40,491 patients who underwent total knee arthroplasty, 7567 (18.7%) had diabetes, 464 (1.1%) underwent revision arthroplasty, and 287 (0.7%) developed a deep infection. Compared with the patients without diabetes, no association between controlled diabetes (HbA1c < 7%) and the risk of revision (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.99 to 1.76), risk of deep infection (OR, 1.31; 95% CI, 0.92 to 1.86), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.84; 95% CI, 0.60 to 1.17) was observed. Similarly, compared with patients without diabetes, no association between uncontrolled diabetes (HbA1c ≥ 7%) and the risk of revision (OR, 1.03; 95% CI, 0.68 to 1.54), risk of deep infection (OR, 0.55; 95% CI 0.29 to 1.06), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.70; 95% CI, 0.43 to 1.13) was observed.
No significantly increased risk of revision arthroplasty, deep infection, or deep venous thrombosis was found in patients with diabetes (as defined on the basis of preoperative HbA1c levels and other criteria) compared with patients without diabetes in the study population of patients who underwent elective total knee arthroplasty.
The Journal of Bone and Joint Surgery 02/2013; 95A(6). DOI:10.2106/JBJS.L.00109 · 5.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Selective patellar resurfacing continues in total knee arthroplasty (TKA). We define the demographics of patients selected for this procedure and report their short-term, aseptic revision rate. A community-based Total Joint Replacement Registry (TJRR) comprising 39,000 TKAs with median follow-up of 24.5 months was evaluated. Patients who underwent bicompartmental TKA were younger (p < 0.001), suffered posttraumatic arthrosis (p < 0.001), and receive hybrid fixation (p < 0.001). In multivariate analysis, the unresurfaced patella is an independent risk factor for early revision with a relative increased risk of 2.3 (95% CI, 1.4-3.7). The cumulative survivorship at 6 years for tricompartmental TKA is 98.1 versus 93.6% for bicompartmental knees (p < 0.001). Despite selecting patients with presumably healthier patellofemoral joints for bicompartmental TKA, the unresurfaced patella remains a risk factor for early revision.
The journal of knee surgery 07/2012; 26(2). DOI:10.1055/s-0032-1319787 · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The optimal method of prophylaxis for the prevention of pulmonary embolism in patients undergoing total hip arthroplasty remains controversial. Guidelines appear to be contradictory. The purpose of the present study was to examine whether a best prophylactic agent exists for the prevention of postoperative pulmonary embolism and whether the type of anesthesia affects the rates of pulmonary embolism.
From 2001 to 2008, a total joint registry from a nationwide health maintenance organization was evaluated to determine the rates of pulmonary embolism, fatal pulmonary embolism, and death among 17,595 patients without a history of venous thromboembolism who were managed with unilateral total hip arthroplasty. All patients were followed for ninety days postoperatively. Data were abstracted electronically and were validated through chart reviews. Multivariate logistic regression models were used to assess associations between the types of prophylaxis and anesthesia that were used and pulmonary embolism while adjusting for other risk factors.
Patients received either mechanical prophylaxis alone (N = 1533) or chemical prophylaxis (aspirin [N = 934], Coumadin [warfarin] [N = 6063], or low-molecular-weight heparin [N = 7202]) with or without mechanical prophylaxis. The rate of pulmonary embolism was 0.41% (95% confidence interval [CI], 0.32% to 0.51%) overall, 0.37% (95% CI, 0.05% to 0.70%) for mechanical prophylaxis, 0.43% (95% CI, 0.01% to 0.85%) for aspirin, 0.43% (95% CI, 0.26% to 0.59%) for Coumadin, 0.40% (95% CI, 0.26% to 0.55%) for low-molecular-weight heparin, 0.43% (95% CI, 0.28% to 0.58%) for general anesthesia, and 0.40% (95% CI, 0.28% to 0.52%) for non-general anesthesia. The mortality rate was 0.51% (95% CI, 0.40% to 1.01%) overall, 0.67% (95% CI, 0.23% to 1.34%) for mechanical prophylaxis, 0.64% (95% CI, 0.13% to 1.28%) for aspirin, 0.51% (95% CI, 0.33% to 1.02%) for Coumadin, 0.42% (95% CI, 0.27% to 0.83%) for low-molecular-weight heparin, 0.51% (95% CI, 0.35% to 0.67%) for general anesthesia, and 0.50% (95% CI, 0.36% to 0.64%) for non-general anesthesia. Regression models did not show any association between the type of prophylaxis used or the choice of anesthesia and increased odds of pulmonary embolism when adjusting for age, sex, and American Society of Anesthesiologists score.
No clinical differences were detected among the types of prophylaxis against venous thromboembolism or the types of anesthesia with respect to pulmonary embolism, fatal pulmonary embolism, or death on the basis of prospective collection of data by a contemporary total joint registry.
The Journal of Bone and Joint Surgery 10/2011; 93(19):1767-72. DOI:10.2106/JBJS.J.01130 · 5.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Accurate projections of future demand require constant updates of current data. This article reviews the most recent usage data for primary total joint arthroplasty (TJA) in a community-based hospital system with 3.2 million members. We used administrative databases to determine plan membership, surgical volume, and age-adjusted incidence rates for TJA from 1996 through 2009. The annual growth rate in surgical volume peaked in 2002 at 18% and decreased to 3% by 2009. The annual growth rate for age-adjusted incidence rates peaked in 2002 at 13% and declined to 2% in 2009. In our population, the incidence of TJA continues to rise but at a much slower pace than in recent years.
The Journal of arthroplasty 09/2011; 26(6 Suppl):124-8. DOI:10.1016/j.arth.2011.03.043 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prophylaxis for pulmonary embolism (PE) prevention in total knee arthroplasty remains controversial. A joint registry evaluated venous thromboembolism prophylaxis and anesthesia impact on the incidence of PE, fatal PE, and death. Patients received mechanical prophylaxis alone or chemical with or without mechanical prophylaxis. The overall PE incidence was 0.45%; fatal PE, 0.01%; and death, 0.31%. The only significant difference in any outcome was the incidence of PE between Coumadin and mechanical prophylaxis alone. Variables associated with a higher incidence of PE were age, an American Society of Anesthesiologists score of 3 or higher, and the use of general anesthesia. Based on the findings, general anesthesia can be discouraged, and only Coumadin fared better than mechanical prophylaxis alone, whereas other forms of chemical prophylaxis revealed no significant differences.
The Journal of arthroplasty 06/2011; 27(2):167-72. DOI:10.1016/j.arth.2011.04.006 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We reviewed 90-day readmission rates for 9150 patients with a primary total hip or knee arthroplasty performed between April 2001 and December 2004. Patients with an American Society of Anesthesiologists score of 3 or greater or with perioperative complications were excluded. We correlated the readmission rate with discharge disposition to either skilled nursing facilities (SNFs) or Home. Of the 9150 patients identified, 1447 were discharged to an SNF. After statistically adjusting for sex, age and American Society of Anesthesiologists scores, total hip arthroplasty and total knee arthroplasty patients discharged to SNFs had higher odds of hospital readmission within 90 days of surgery than those discharged home (total hip arthroplasty: odds ratio = 1.9; 95% confidence interval, 1.2-3.2; P = .008; total knee arthroplasty: odds ratio = 1.6; 95% confidence interval, 1.1-2.4; P = .01). Healthy patients discharged to SNFs after primary total joint arthroplasty need to be followed closely for complications.
The Journal of arthroplasty 02/2009; 25(1):114-7. DOI:10.1016/j.arth.2008.11.007 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are limited population-based data on utilization, outcomes, and trends in total knee arthroplasty (TKA). The purpose of this study was to examine TKA utilization and short-term outcomes in a pre-paid health maintenance organization (HMO), and to determine whether rates and revision burden changed over time. We also studied whether this population is representative of the general population in California and in the United States.
Using hospital utilization and membership databases from 1995 through 2004, we calculated incidence rates (IRs) of primary and revision TKA for every 10,000 health plan members. The demographics of the HMO population were compared to published census data from California and the United States.
The age and sex distributions of the study population were similar to those of the general population in California and the United States. 15,943 primary TKAs and 1,137 revision TKAs were performed during the 10-year period. Patients below the age of 65 accounted for one-third of all primary replacements and one-third of all revision replacements. IRs of primary TKAs increased from 6.3 per 10,000 in 1995 to 11.0 per 10,000 in 2004, at a rate of 5% per year (p<0.001). IRs of revision TKAs increased from 0.41 per 10,000 in 1995 to 0.74 per 10,000 in 2004 (p=0.4). Revision burden remained stable over the 10-year observation period. Surgical complications were higher in revision TKA than in primary TKA (10% vs. 7.7%; p=0.007). 90 day complication rates for primary and revision TKA including death were 0.3% and 0.6% (p=0.1) and for pulmonary embolism 0.5% and 0.4% (p=0.6). 90 day re-admission rates for primary and revision TKA including infection were 0.5% and 4.2% (p<0.001), for myocardial infarction 0.1% each, and for pneumonia 0.2% and 0.4% (p=0.08).
The incidence of primary and revision TKA increased between 1995 and 2005. The rates of postoperative complications were low. Comparisons of the study population and the underlying general populations of interest indicate that this population can be used to predict the incidences and outcomes of TKA in the general population of California and of the United States as a whole.