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Award-winning study identifies patient conditions that warrant caution for short-stay TJA
Older patients, those with a BMI or diabetes were not linked with an increased risk for perioperative medical complications.
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Researchers of an award-winning study found chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and cirrhosis were independent risk factors for a late complication after primary total joint arthroplasty. Having just one of these risk factors was linked with a 50% chance such a complication would occur.
“A significant number of major complications, it was 84% in our study, occurred over 24-hours postoperatively,” P. Maxwell Courtney, MD, said during his presentation of the James A. Rand winning research, which was presented at the American Association of Hip and Knee Surgeons Annual Meeting. “If you have a history of [chronic obstructive pulmonary disease] COPD, congestive heart failure, coronary artery disease and cirrhosis, you should not undergo short-stay or outpatient total joint arthroplasty [TJA].”
He told Orthopedics Today, “While it seems intuitive that ‘sicker’ patients would be at high risk for complications and should not undergo outpatient TJA, it was surprising to see the risk factors that were not associated with increased complications. We found that patients over age 75, [those] a BMI over 35 or a history of diabetes are not at higher risk for later perioperative complications and should not be excluded from short-stay TJA protocols.”
Courtney and his colleagues retrospectively reviewed prospectively collected data for 1,012 patients who underwent primary total hip or knee arthroplasty during a 10-month period.
Courtney and his colleagues found 6.9% of patients experienced a medical complication during their hospital stay, with 84% of these complications occurring after 24 hours postoperatively. COPD, congestive heart failure, coronary artery disease and cirrhosis were independent risk factors for a complication after 24 hours postoperatively with adjusted odds ratios of 4.16, 9.71, 2.8 and 8.43, respectively.
To identify the ideal candidate for short-stay TJA, researchers developed a model based on these comorbidities with a 6-point score. According to results, patients with a score of 0 had a 3.1% probability of complications after 24 hours postoperatively. However, patients older than 75 years, those with a BMI greater than 35 and patients with diabetes did not show statistically significant difference for experiencing a complication after 24 hours postoperatively.
“[If] you have one of two of those variables, which would get you up to a score of 3, you would almost have a 50% chance of experiencing a complication. So just one of those risk factors can make a huge deal in getting one of these late complications,” Courtney said during his presentation.
According to Courtney, this study was the experience found at a single institution, and other hospitals may have patients with different demographics and comorbidity mixes. The results also did not define the optimal length of stay, which he said will depend on the hospital’s risk tolerance. For both of these reasons, each institution should develop their own threshold for risk and readmissions. – by Casey Tingle
References:
Courtney PM, et al. Who should not undergo short-stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 6-9, 2014; Dallas.
For more information:
P. Maxwell Courtney, MD, can be reached at Penn Presbyterian Medical Center, 51 North 39th St., Philadelphia, PA 19104; email: Paul.Courtney@uphs.upenn.edu.
Disclosure: Courtney reports no relevant financial disclosures.