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Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature

  • Quality and Cost Control in TJA (B Waddell, section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

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.

Summary

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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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet. 2012;380(9855):1768–77.

    Article  PubMed  Google Scholar 

  2. • Bozic KJ, Kamath AF, Ong K, Lau E, Kurtz S, Chan V, et al. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res. 2015;473(6):2131–8. This retrospective study analyzed the Nationwide Inpatient Sample database to evaluate the epidemiologic and economic trends in revision arthroplasty between 2005 and 2010. The authors determined that revision total knee arthroplasty (TKA) increased by 39% and revision total hip arthroplasty (THA) by 23% between 2005 and 2010. In addition, they found that patients who undergo revision THA are generally older and sicker than those who undergo revision TKA, which likely contributes to the higher mean hospitalization cost for revision THA as compared to revision TKA.

    Article  PubMed  Google Scholar 

  3. Judge A, Arden NK, Cooper C, Kassim Javaid M, Carr AJ, Field RE, et al. Predictors of outcomes of total knee replacement surgery. Rheumatology (Oxford). 2012;51(10):1804–13.

    Article  Google Scholar 

  4. Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder H, et al. Patient charcteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg. 2008;51(6):428–36.

    PubMed  PubMed Central  Google Scholar 

  5. Lingard EA, Katz JN, Wright EA, Sledge CB. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004;86-A(10):2179–86.

    Article  PubMed  Google Scholar 

  6. Roder C, Parvizi J, Eggli S, Berry DJ, Muller ME, Busato A. Demographic factors affecting long-term outcome of total hip arthroplasty. Clin Orthop Relat Res. 2003;417:62–73.

    Google Scholar 

  7. Ravi B, Jenkinson R, Austin PC, Croxford R, Wasserstein D, Escott B, et al. Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study. BMJ. 2014;348:g3284.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Martin JR, Jennings JM, Dennis DA. Morbid obesity and total knee arthroplasty: a growing problem. J Am Acad Orthop Surg. 2017;25(3):188–94.

    Article  PubMed  Google Scholar 

  9. Fu MC, McLawhorn AS, Padgett DE, Cross MB. Hypoalbuminemia is a better predictor than obesity of complications after total knee arthroplasty: a propensity score-adjusted observational analysis. HSS J. 2017;13(1):66–74.

    Article  PubMed  Google Scholar 

  10. George J, Newman JM, Ramanathan D, Klika AK, Higuera CA, Barsoum WK. Administrative databases can yield false conclusions—an example of obesity in total joint arthroplasty. J Arthroplast. 2017; doi:10.1016/j.arth.2017.01.052.

  11. Belmont PJ Jr, Goodman GP, Kusnezov NA, Magee C, Bader JO, Waterman BR, et al. Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence. J Bone Joint Surg Am. 2014;96(24):2025–31.

    Article  PubMed  Google Scholar 

  12. Waterman BR, Belmont PJ Jr, Bader JO, Schoenfeld AJ. The total joint arthroplasty cardiac risk index for predicting perioperative myocardial infarction and cardiac arrest after primary total knee and hip arthroplasty. J Arthroplast. 2016;31(6):1170–4.

    Article  Google Scholar 

  13. • Ali A, Lindstrand A, Sundberg M, Flivik G. Preoperative anxiety and depression correlate with dissatisfaction after total knee arthroplasty: a prospective longitudinal cohort study of 186 patients, with 4-year follow-up. J Arthroplast. 2017;32(3):767–70. This prospective cohort study evaluated patient-reported outcomes 4 years after total knee arthroplasty and found that patients with a preoperative diagnosis of anxiety or depression are six times as likely to report that they are not satisfied with the result of their operation. The overall rate of dissatisfaction among the patients in the study was 15%, consistent with previously reported rates.

    Article  Google Scholar 

  14. Gold HT, Slover JD, Joo L, Bosco J, Iorio R, Oh C. Association of depression with 90-day hospital readmission after total joint arthroplasty. J Arthroplast. 2016;31(11):2385–8.

    Article  Google Scholar 

  15. Browne JA, Sandberg BF, D'Apuzzo MR, Novicoff WM. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplast. 2014;29(3):481–3.

    Article  Google Scholar 

  16. Rasouli MR, Menendez ME, Sayadipour A, Purtill JJ, Parvizi J. Direct cost and complications associated with total joint arthroplasty in patients with preoperative anxiety and depression. J Arthroplast. 2016;31(2):533–6.

    Article  Google Scholar 

  17. • Bozic KJ, Lau E, Ong K, Chan V, Kurtz S, Vail TP, et al. Risk factors for early revision after primary TKA in Medicare patients. Clin Orthop Relat Res. 2014;472(1):232–7. In this analysis of the Medicare 5% national sample administrative database, there was an increase in the rate of revision within 1 year of primary TKA in patients with a diagnosis of depression. The only patient-specific variable that was associated with a higher risk of early revision was a diagnosis of chronic obstructive pulmonary disease.

    Article  PubMed  Google Scholar 

  18. • Bozic KJ, Lau E, Ong K, Chan V, Kurtz S, Vail TP, et al. Risk factors for early revision after primary total hip arthroplasty in Medicare patients. Clin Orthop Relat Res. 2014;472(2):449–54. In this analysis of the Medicare 5% national sample administrative database, there was an increase in the rate of revision within 1-year of primary THA in patients with a diagnosis of depression. No other patient-specific variables were associated with a higher risk of early revision than depression.

    Article  PubMed  Google Scholar 

  19. Klement MR, Nickel BT, Penrose CT, Bala A, Green CL, Wellman SS, et al. Psychiatric disorders increase complication rate after primary total knee arthroplasty. Knee. 2016;23(5):883–6.

    Article  PubMed  Google Scholar 

  20. Issa K, Boylan MR, Naziri Q, Perfetti DC, Maheshwari AV, Mont MA. The impact of hepatitis C on short-term outcomes of total joint arthroplasty. J Bone Joint Surg Am. 2015;97(23):1952–7.

    Article  PubMed  Google Scholar 

  21. • Jiang SL, Schairer WW, Bozic KJ. Increased rates of periprosthetic joint infection in patients with cirrhosis undergoing total joint arthroplasty. Clin Orthop Relat Res. 2014;472(8):2483–91. A retrospective review of the State Inpatient Database showed that a diagnosis of cirrhosis was independently associated with an increased risk of prosthetic joint infection, increased risk of re-admission within 180-days of surgery, and increased risk of mortality. In a multivariate analysis, cirrhosis and hepatitis C had the highest independent hazard ratios for risk of prosthetic joint infection.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tiberi JV 3rd, Hansen V, El-Abbadi N, Bedair H. Increased complication rates after hip and knee arthroplasty in patients with cirrhosis of the liver. Clin Orthop Relat Res. 2014;472(9):2774–8.

    Article  PubMed  PubMed Central  Google Scholar 

  23. • Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Late complications following elective primary total hip and knee arthroplasty: who, when, and how? J Arthroplast. 2017;32(3):719–23. This prospective study of elective primary total joint arthroplasty was designed to identify comorbidities that would make patients poor candidates for short-stay arthroplasty. The authors found that cirrhosis was independently associated with major complications more than 24-h postoperative after total joint arthroplasty.

    Article  Google Scholar 

  24. Deleuran T, Vilstrup H, Overgaard S, Jepsen P. Cirrhosis patients have increased risk of complications after hip or knee arthroplasty. Acta Orthop. 2015;86(1):108–13.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kamath AF, McAuliffe CL, Kosseim LM, Pio F, Hume E. Malnutrition in joint arthroplasty: prospective study indicates risk of unplanned ICU admission. Arch Bone Jt Surg. 2016;4(2):128–31.

    PubMed  PubMed Central  Google Scholar 

  26. Nelson CL, Elkassabany NM, Kamath AF, Liu J. Low albumin levels, more than morbid obesity, are associated with complications after TKA. Clin Orthop Relat Res. 2015;473(10):3163–72.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Walls JD, Abraham D, Nelson CL, Kamath AF, Elkassabany NM, Liu J. Hypoalbuminemia more than morbid obesity is an independent predictor of complications after total hip arthroplasty. J Arthroplast. 2015;30(12):2290–5.

    Article  Google Scholar 

  28. Yi PH, Frank RM, Vann E, Sonn KA, Moric M, Della Valle CJ. Is potential malnutrition associated with septic failure and acute infection after revision total joint arthroplasty? Clin Orthop Relat Res. 2015;473(1):175–82.

    Article  PubMed  Google Scholar 

  29. • Bohl DD, Shen MR, Kayupov E, Cvetanovich GL, Della Valle CJ. Is hypoalbuminemia associated with septic failure and acute infection after revision total joint arthroplasty? A study of 4517 patients from the National Surgical Quality Improvement Program. J Arthroplast. 2016;31(5):963–7. This retrospective review of the national Surgical Quality Improvement Program showed that patients with hypoalbuminemia have a threefold increase in the risk of having a septic indication for revision arthroplasty. Hypoalbuminemia was also associated with a twofold increase in the risk of developing a prosthetic joint infection within 30 days of aseptic revision.

    Article  Google Scholar 

  30. Bohl DD, Shen MR, Kayupov E, Della Valle CJ. Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after Total joint Arthroplasty. J Arthroplast. 2016;31(1):15–21.

    Article  Google Scholar 

  31. Kulie T, Groff A, Redmer J, Hounshell J, Schrager S. Vitamin D: an evidence-based review. J Am Board Fam Med. 2009;22(6):698–706.

    Article  PubMed  Google Scholar 

  32. Michelson JD, Charlson MD. Vitamin D status in an elective orthopedic surgical population. Foot Ankle Int. 2016;37(2):186–91.

    Article  PubMed  Google Scholar 

  33. Jansen JA, Haddad FS. High prevalence of vitamin D deficiency in elderly patients with advanced osteoarthritis scheduled for total knee replacement associated with poorer preoperative functional state. Ann R Coll Surg Engl. 2013;95(8):569–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Maniar RN, Patil AM, Maniar AR, Gangaraju B, Singh J. Effect of preoperative vitamin D levels on functional performance after total knee arthroplasty. Clin Orthop Surg. 2016;8(2):153–6.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lavernia CJ, Villa JM, Iacobelli DA, Rossi MD. Vitamin D insufficiency in patients with THA: prevalence and effects on outcome. Clin Orthop Relat Res. 2014;472(2):681–6.

    Article  PubMed  Google Scholar 

  36. Maier GS, Horas K, Seeger JB, Roth KE, Kurth AA, Maus U. Is there an association between periprosthetic joint infection and low vitamin D levels? Int Orthop. 2014;38(7):1499–504.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Maier GS, Maus U, Lazovic D, Horas K, Roth KE, Kurth AA. Is there an association between low serum 25-OH-D levels and the length of hospital stay in orthopaedic patients after arthroplasty? J Orthop Traumatol. 2016;17(4):297–302.

    Article  PubMed  PubMed Central  Google Scholar 

  38. • Yang Z, Liu H, Xie X, Tan Z, Qin T, Kang P. The influence of diabetes mellitus on the post-operative outcome of elective primary total knee replacement: a systematic review and meta-analysis. Bone Joint J. 2014;96:1637–43. This systematic review and meta-analysis of 14 studies provides some of the most compelling evidence that diabetes mellitus is associated with an increased risk of complication after elective total knee arthroplasty. Their analysis shows that patients with diabetes mellitus have a higher risk of deep infection, aseptic loosening and lower functional scores than nondiabetic patients.

    Article  PubMed  Google Scholar 

  39. Adams AL, Paxton EW, Wang JQ, Johnson ES, Bayliss EA, Ferrara A, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013;95(6):481–7.

    Article  PubMed  Google Scholar 

  40. Maradit Kremers H, Lewallen LW, Mabry TM, Berry DJ, Berbari EF, Osmon DR. Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty. J Arthroplast. 2015;30(3):439–43.

    Article  Google Scholar 

  41. Tischler EH, Matsen Ko L, Chen AF, Maltenfort MG, Schroeder J, Austin MS. Smoking increases the rate of reoperation for infection within 90 days after primary total joint arthroplasty. 2017;99(4):295–304.

  42. Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am. 2015;97(13):1049–58.

    Article  PubMed  Google Scholar 

  43. Kokubun BA, Manista GC, Courtney PM, Kearns SM, Levine BR. Intra-articular knee injections before total knee arthroplasty: outcomes and complication rates. J Arthroplast. 2017; doi:10.1016/j.arth.2017.01.041.

  44. Marsland D, Mumith A, Barlow IW. Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty. Knee. 2014;21(1):6–11.

    Article  PubMed  Google Scholar 

  45. Amin NH, Omivi D, Kuczynski B, Cushner FD, Scuderi GR. The risk of a deep infection associated with Intraarticular injections before a total knee arthroplasty. J Arthroplast. 2016;31(1):240–4.

    Article  Google Scholar 

  46. Pereira LC, Kerr J, Jolles BM. Intra-articular steroid injection for osteoarthritis of the hip prior to total hip arthroplasty: is it safe? a systematic review. Bone Joint J. 2016;98-B(8):1027–35.

    Article  CAS  PubMed  Google Scholar 

  47. Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplast. 2016;31(4):820–3.

    Article  Google Scholar 

  48. Ramos NL, Karia RJ, Hutzler LH, Brandt AM, Slover JD, Bosco JA. The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty. J Arthroplast. 2014;29(4):674–7.

    Article  Google Scholar 

  49. Sikora-Klak J, Zarling B, Bergum C, Flynn JC, Markel DC. The effect of comorbidities on discharge disposition and readmission for Total joint Arthroplasty patients. J Arthroplast. 2016; doi:10.1016/j.arth.2016.11.035.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Forrest H. Schwartz & Jeffrey Lange

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Correspondence to Jeffrey Lange.

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Schwartz, F.H., Lange, J. Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature. Curr Rev Musculoskelet Med 10, 346–355 (2017). https://doi.org/10.1007/s12178-017-9421-8

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