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Obese patients have high risk of complications after TJR, but high BMI does not contraindicate surgery

Obese patients who undergo total joint replacement have a higher risk of complications, but there is no body mass index level where the surgery would be contraindicated, according to a recent presentation, here.

“We understand that notable obesity increases most complications,” Daniel J. Berry, MD, said at the Current Concepts in Joint Replacement Winter Meeting. “There is no [body mass index] BMI threshold, but we should use good judgment in whether we operate on patients at a high BMI, and remember the rate of complications seems to rise fast above a BMI of 40.”

For patients who undergo total hip arthroplasty, complications such as nerve injury, infection and wound healing are increased, according to the abstract. Berry noted that although obese patients have lower functional and activity scores compared to nonobese patients, obese patients start with lower functional and activity scores so pain relief and postoperative change is comparable.

Berry said strategies for patients to lose weight before joint replacement surgery include diet and bariatric surgery. However, he noted weight loss through surgery may result in a patient who is malnourished. If a surgeon decides to perform total joint replacement surgery on an obese patient, Berry recommended optimizing metabolic, wound and anticoagulant management to reduce postoperative complications. Overall, he said it is important to include the patient in the decision-making process.

“Use good surgical judgment, consider carefully in each patient [whether] the risks are greater than the benefits and engage the patient in the shared decision-making process,” he said. “They understand they have a high body mass index. It is helpful for them to be engaged in the discussion so whatever the outcome of surgery they feel like they participated in the decision.”

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Patient age, diabetes increase mortality risk after TKA

Older patients and patients with diabetes have an increased risk of mortality and postoperative complications following primary total unilateral knee arthroplasty, according to recently published data.

Philip J. Belmont, Jr., MD and colleagues studied 15,321 patients who underwent primary unilateral total knee arthroplasty (TKA). They found that the results “underscore that diabetes mellitus and increased age are notable risk factors for mortality.”

The patients in the study had a mean age of 67.3 years. Overall, 61.2% of the patients were classified as having obesity, 18.2% of the patients had diabetes, and 50% of the patients were graded as class 3 or higher on the basis of the American Society of Anesthesiologists (ASA) classification system.

The researchers found a 30-day mortality rate of 0.18%. Overall, 1.83% of the patients had major complications and 5.6% of the patients experienced overall complications. Cardiac arrest (44%), systemic shock (18.5%) and renal failure (18.5%) were the most common specific complications among the patients who died. Risk factors for complications after TKA were an age of 80 years or older, operative times greater than 135 minutes, body mass indices of 40 kg/m2 or greater, and ASA classification of 3 or greater.

“The 2.2% mortality or major complication rate that we found for patients who underwent a unilateral TKA confirms the need for diligent medical management during the perioperative period,” Belmont stated in the study.

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Preoperative erythropoietin may reduce allogenic blood transfusion in hip, knee arthroplasty

Researchers performed a systematic review of randomized clinical trials and found using preoperative erythropoietin-stimulating agents increased hemoglobin levels in patients undergoing elective hip and knee arthroplasty.

“Erythropoietin improves postoperative hemoglobin levels and decreases the need for allogeneic blood transfusion in patients undergoing hip or knee surgery,” Khalid Alsaleh, MD, and colleagues wrote in the study.

Alsaleh and colleagues evaluated 26 trials with 3,560 participants who underwent unilateral, bilateral, primary or revision hip or knee arthroplasty, according to the abstract. Patients were given erythropoietin-stimulating agents (ESAs) preoperatively and compared with patients undergoing similar surgeries who received preoperative autologous blood donation, intravenous iron or placebo.

Receiving preoperative ESAs increased hemoglobin levels in that patient group. Between the ESA group and the control groups, the mean hemoglobin level was 7.16 g/L. There was no significant difference between groups for the risk of thromboembolism, according to the abstract.

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Researchers recommend wellness programs for increased number of young TJR patients with obesity

Results from a new total joint replacement database show that the increase in young patients with obesity contributes to increased rates of total joint replacement in the United States, and researchers recommend hospitals and private practices implement wellness programs to improve patient outcomes.

“Postoperative rehabilitation and support programs should target improved physical activity and diet to promote weight loss and a healthier lifestyle. We should focus on standard best practices for physical therapy and health management after joint replacement surgery,” David C. Ayers, MD, chair of the Department of Orthopaedics and Physical Rehabilitation and director of the Musculoskeletal Center of Excellence at the University of Massachusetts Medical School, told Orthopedics Today. “Such standards currently do not exist. Figuring those out, and how to lose weight, should be a priority. It has to be about more than just fixing joint pain. It has to be about long-term health, function and quality of life.”

The joint replacement database, called the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) database, is the result of a four-year, $12 million grant in 2010 to develop a system that tracks process and outcomes in total joint replacement (TJR).

“FORCE-TJR is already the largest joint replacement database in the nation and growing. It is also the only TJR database to include patient-reported outcomes,” Ayers said. “The information being collected by FORCE-TJR has the potential to directly influence clinical best practices, health care policy and the overall health and quality of life for more than 60 million people living with arthritis in the United States.”

The results from the first 9,000 patients enrolled in the database has shown 55% of patients younger than 65 years are obese, compared to 43% of patients who are older than 65 years. Further, 11% of patients younger than 65 years had a body mass index greater than 40 compared to 5% of patients older than 65 years.

Ayers said health wellness programs, such as those used in specialties with patients who have diabetes and heart disease, should be implemented in joint replacement programs.

“Wellness incentives are a big part of health care reform here in Massachusetts. Their effectiveness hasn’t been fully understood, but we have them for a reason,” he said. “Incentives to live a healthier lifestyle benefit the patient and ultimately reduce health care costs for everyone. When you eliminate complications, readmissions and revision surgeries, you also eliminate some very potent cost drivers in the health care system.”

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Hip arthrodesis converted to THA associated with high complication rates

Researchers at the University of Leeds, in Leeds, United Kingdom, found complication rates were high after arthrodesis in eight studies and after conversion from hip arthrodesis to total hip arthroplasty in eleven studies, according to results of a systematic review.

“Arthrodesis of the hip provides excellent rates of union allowing most patients to live a pain-free life for many years,” Sameer Jain, MB, ChB, MRCS, and colleagues wrote in the study. “However, altered hip biomechanics ultimately lead to adjacent joint pain with many suffering from lower back and knee pain. Many of these patients will therefore require conversion [total hip arthroplasty] THA to restore hip function and relieve pain.”

Jain and colleagues analyzed results of 249 hips in eight published studies and found union rates of 37.5% to 100%, patient satisfaction rates of 69% to 100% and an overall 8.4% complication rate. In those studies, adjacent joint pain was reported in the low back in up to 75% of cases and in the ipsilateral knee in up to 57% of cases, according to the abstract.

In 11 studies that investigated conversion to THA, Jain and colleagues noted a 54% complication rate, which was due to factors such as mechanical failure, nerve palsy and deep infection.

“Patients must be aware that although complete pain relief is unlikely, functional improvement can be expected. However, this is a technically challenging procedure with less satisfying results than primary THA,” Jain and colleagues wrote. “Complication and revision rates are high and for this reason, arthrodesis of the hip should be considered with caution in younger, more active patients with greater physical demands. However, with newer implant designs, bearing couples, fixation methods and advances such as computer-assisted surgery, success rates of conversion THA may improve.”

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Good results seen with highly porous acetabular implants in revision THA

Highly porous, commercially pure, titanium matrix acetabular components are safe and efficacious in patients who underwent revision total hip arthroplasties, according to a study recently presented.

“We prefer these highly porous jumbo cups for treatment of chronic discontinuity with major bone loss,” Morteza Meftah, MD, of Ranawat Orthopaedics, Hospital for Special Surgery (HSS) in New York City said. “Non-cemented custom cages, cemented cup/cage combination, or allograft are alternative choice if you want to treat Paprosky III or chronic pelvic discontinuity due to osteolysis. In our hands, Tritanium jumbo cups have reduced or eliminated the need for cup/cage combinations in such cases.”

He added, “The new porous Tritanium theoretically needs less bone (bleeding surface) to osteointegrate. This is important in major revision surgery when the bleeding surface is less than primary. We found that much less (around 30%) of bleeding bony surface is required for fixation with these implants.”

Jumbo cups

Researchers evaluated 24 patients who underwent revision total hip arthroplasty for major acetabular defects with Tritanium acetabular components (Stryker; Mahwah, NJ) between 2007 and 2010, and had a mean follow-up of 4 years. Most patients had a preoperative Paprosky classification of IIIA or IIIB with pelvic discontinuity. There were 10 men and 14 women, and patients had a mean age of 69 years.

Meftah noted the Tritanium cups consist of trabecular metal implants, designed to resemble the trabecular bone structure. The trabecular implants are a highly porous 3-D surface utilizing commercially pure titanium (CPTi) powder technology.

“The jumbo cups are about 10 mm larger than the native socket, 58 mm or larger in women and 62 mm or larger in men,” Meftah said. “The use of these highly porous cups has theoretically improved osseointegration, due to a small percentage of the bleeding bone that is required.”

During the revision procedures, surgeons performed progressive reaming to obtain a bleeding bone interface. The interference fit between the anterior inferior iliac spine, pubis and ischium was achieved with the use of Tritanium jumbo cups. Bone graft was utilized before placement of the cup in the non-bleeding portions of the defect.

“It is a good idea to use a trial component to test the stability prior to the actual implant. Use the distraction technique in chronic discontinuity to obtain a wedge interface with 2-mm to 5-mm oversize jumbo cups and at least two to five screws to enhance fixation,” Meftah said. There were no cup/cages or wedges used in this series. Most patients required a cup diameter of 62 mm or bigger, according to Meftah.

Results

The investigators analyzed patients’ radiographic and clinical results, and extent of osseointegration. The WOMAC score was 30.5 points, the patient-administered questionnaire (PAQ) score was 25.2 and HSS score was 25.3, with Meftah noting that lower numbers for the WOMAC and PAQ are better and higher numbers for the HSS are better. All three clinical outcomes were good at final follow-up.

The abduction angle was 43° with an anteversion of 20°. Osseointegration occurred in all cups, with a minimum osseointegration incidence of 30% and maximum of 75%. “The most osseointegration was in zone I, which was superior, and zone VI, which was posterior,” Meftah said.

He added, “We had good patient satisfaction with significant improvement of pain. None of the patients had any complications, dislocations, infections or failure of osseointegration at final follow-up.” – by Renee Blisard Buddle.

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Socially isolated patients with arthritis have more pain after THR

SAN DIEGO – Socially isolated patients with osteoarthritis are nearly three times more likely to experience serious ongoing pain after total hip replacement than patients with good social ties, according to researchers from Hospital for Special Surgery.

“Previous studies have shown that social isolation is a risk factor for poor health outcomes,” Lisa A. Mandl, MD, MPH, from Hospital for Special Surgery, stated. “Studies show that people who don’t have good social ties are at increased risk of suffering a heart attack or stroke, and even dying, compared to those who enjoy the social support of family, friends and the community.”

In the study, social isolation was defined based on whether the patients were married, were members of any community or religious groups or had fewer than six friends or relatives. Mandl and colleagues noted that, although the 132 rheumatoid arthritis (RA) patients and 392 osteoarthritis (OA) patients had similar demographics and proportions of socially isolated patients, the OA patients had a statistically significant association with postoperative decreased WOMAC scores and social isolation, according to the abstract.

Severe social isolation in OA patients was also significantly associated with WOMAC scores less than 60 points and 2.9 times postoperative pain than control patients, but it was not associated with poor postoperative function.

Patients with OA who underwent a total hip replacement had worse pain outcomes than patients with RA. In RA patients, severe social isolation was significantly associated with poor postoperative function, but not postoperative pain.

“We believe further prospective studies should be done to determine whether interventions to evaluate and improve patients’ social ties before surgery could lead to a better pain outcome after hip replacement,” Mandl said. “It could be a way to improve outcomes without medication or other costly interventions. I see no downside to helping patients get the social support they may need to improve their quality of life.”

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Study: Day-of-surgery discharge found effective for UKA patients using refined perioperative pathway

Day-of-surgery discharges can be safe, efficient and increase patient satisfaction when using a refined perioperative pathway for appropriately selected patients who undergo unicompartmental knee arthroplasty, according to results of a recently published study.

“[Unicompartmental knee arthroplasty] UKA patients can be discharged on the day of surgery with a high satisfaction rate,” Steven Barnett, MD, from the Hoag Orthopedic Institute in Irvine, Calif., told Orthopedics Today. “This provides orthopedic surgeons with the ability to effectively treat these patients while minimizing cost associated with this procedure.

Barnett said surgeons at his institution recognized that UKA patients had less difficulty with pain management, decreased length of stay and achieved better results in physical therapy during hospitalization.

“This led us to begin managing these patients with a 23-hour overnight stay and eventually discharging them on the day of surgery,” Barnett said.

Barnett said within a 2-year to 3-year period, surgeons moved UKA patients from an inpatient setting to a day of surgery discharge after adopting techniques related to general and regional anesthesia, local soft-tissue infiltration and oral perioperative pain management.

Under this perioperative pathway, he and colleagues successfully discharged 160 consecutive UKA patients who were a mean of 65 years old with a mean American Society of Anesthesiology class of 1.8. The mean recovery room time was 121 minutes and no patients had uncontrolled pain or nausea that required an overnight stay. Patients had high satisfaction scores and researchers noted significant improvements in Knee Society Clinical Rating System scores.

“Our current algorithm is dependent upon patient education prior to surgery. Patients are instructed on crutch use, postoperative wound management, precautions, and [deep vein thrombosis] DVT prophylaxis at an extensive preoperative visit,” Barnett said. “Pain management on the day of surgery entails use of multimodal oral analgesics started prior to the procedure combined with both regional nerve blocks and peri-articular infiltration of a local anesthetic mixture. Activity limitations and weight bearing precautions are reinforced prior to discharge from the surgery center.”

Barnett said other surgeons performing UKA have adopted the pathway described in this study with success.

“The authors are confident that results will continue to be optimal and look forward to adapting these protocols to other arthroplasty procedures moving forward,” he said.

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Omega-3 fatty acids may help reduce risk of hip fracture in postmenopausal women

The risk of hip fractures in postmenopausal women may be reduced through consuming more omega-3 polyunsaturated fatty acids, according to a study published in the Journal of Bone and Mineral Research.

“We don’t yet know whether omega-3 supplementation would affect results for bone health or other outcomes,” Tonya Orchard, PhD, RD, LD, from Ohio State University, stated in a press release. “Though it is premature to make a nutrition recommendation based on this work, I do think this study adds a little more strength to current recommendations to include more omega-3s in the diet in the form of fish, and suggests that plant sources of omega-3 may be just as important for preventing hip fractures in women.”

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ORIF prevented need for later THA in acetabular fracture patients

Long-term follow-up showed that open reduction and internal fixation successfully treated displaced acetabular fractures in patients without the need for subsequent total hip arthroplasty, according to this study.

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