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Percentage of Procedures
joint infection
0.35
US National Databases– Total Knee Arthroplasty: Lessons Learned
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39
UKA <65 years old
0.30
0.25
0.20
0.15
0.10
0.05
0.00
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
UKA
≥65 years old
TKA <65 years old
≥65 years old
TKA
0.19
0.01
0.02
0.01
Extensor
mechanism
disruption
0.48
0.00
0.36
complication
0.00
0.00
Neural
deficit
DeathWound
0.06
0.05
Patellofemoral
0.31
0.62
0.15
0.13
0.02
Instability/
Tibiofemora
Dislocation
0.39
Myocardial
0.09
0.50
0.13
infraction
0.02
0.02
Bearing
surface
wear
1.04
0.29
0.09
0.02
0.02
0.01
Osteolysis Va scular
1.19
0.71
0.63
Deep
periprosthetic
0.01
0.90
0.00
Pulmonary
embolism
0.10
0.70
0.04
injury
0.86
0.15
0.11
1.72
1.29
Thromboembolic
0.16
0.04
Implant
loosening
1.26
disease
0.14
0.06
2.20
0.88
0.11
0.07
0.05
Periprosthetic
fracture
1.50
0.13
Arthroscopy
of knee
0.24
0.05
Implant
fracture of
tibial Insert
dissociation
1.09
0.06
0.16
0.13
0.06
Medial
collateral
ligament
injury
9.81
6.81
3.72
2.67
Stiness Hospitalization
0.17
0.11
0.12
0.10
0.08
0.15
Bleeding
8.44
4.93
0.15
. Fig. 39.1 Outcomes following UKA and TKA within 90days of follow-up for patients younger and older than 65years of age. (Adapted
from Hansen etal. (2018); courtesy of the U.S.National Library of Medicine)
0.30
0.20
14.03
10.41
than 65years of age. A total of 25,135 UKA and 362,589
TKA matched patients were analyzed in the study. UKA
patients had signicantly lower rates of wound complications, pulmonary embolism, periprosthetic joint
infection, re-admission, and death, compared to TKA
patients (. Fig. 39.1). However, UKA had lower survivorship compared to TKA, regardless of age. Specically, at the 7-year postoperative time point, survivorship
for the younger population was 74.4% for UKA and
91.9% for TKA, and survivorship for the elderly population was 80.9% for UKA and 95.7% for TKA.
39.4 Primary andRevision Total Knee
39.4.1 General Outcomes
TKAs are a popular surgical option for patients in the
United States, and their utilization has been increasing.
Survey of the NIS and Census Bureau data sets between
1993 and 2012 showed a total of 7.8 million primary
TKAs were performed in the United States and the
> The study determined that although UKA has fewer
complications and hospital re-admissions compared
to TKA, the survivorship of UKA was lower than
TKA within 10years follow-up.
Arthroplasty
number of surgeries increased by 224% over that time
(Kurtz etal.
2016). This annual TKA volume increase
was more pronounced after the year 2000. Prior to 2000,
the average increase was 10,520 procedures per year. This
accelerated to an average increase of 32,730 procedures/
year after 2000, nearly tripling the rate of increase. As
evidence of the increasing trend in popularity, TKAs
in Massachusetts from the SID data set experienced a
similar 80% increase from 10.8 procedures/10,000 in
2002 to 19.4 procedures/10,000 in 2011. The trends in
Massachusetts were similar to the trends seen across the
nation as a whole for that time period, which experienced
a 69% increase. National utilization was 12.2 procedures
per 10,000in 2002 and rose to 20.65in 2011, as seen from
the NIS data set. This is an interesting contrast with the
Medicare population examined over a similar time period.
Analysis of the Medicare database within the PearlDiver
2005 to 2011 data set showed a modest increase in annual
utilization from a minimum of 287,006in 2006 to a maximum of 301,956in 2010 (Nwachukwu etal.
2015).
Databases allow for objective measures of utilization of services across racial, gender, and regional lines
and show that there are geographic, racial, gender,
and patient-age-dependent variations in the utilization, complication rates, and reimbursement for TKAs.
Differences exist between the region with the most
procedures performed and the region with the highest
annual increase. The utilization of TKAs was found
to be less from many minority groups as compared to
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white patients. The complication types and rates are different between males and females following TKA, and
reimbursements and outcomes vary signicantly by age.
More detail on each of these variables is provided below.
39.4.1.1 Race andGender
The use of the SID from multiple states has been
explored by Zhang etal. to examine racial and ethnic
disparities in utilization of primary TKA (Zhang et al.
2016). The SID data from Arizona, Colorado, Iowa,
North Carolina, New Jersey, Rhode Island, Wisconsin,
and Florida demonstrated an increase in TKA utilization
over 2002 to 2008 for all racial groups. However, lower
rates of TKA utilization were observed for minorities.
After adjusting for co-variables such as differing patient
demographics, health conditions, and socioeconomic
status, the rate of TKA utilization was still signicantly
lower for black, Hispanic, Asian, Native American, and
mixed-race patients compared with the rate for white
patients. This means that the healthcare system characteristics explained only some of the racial disparities
in utilization of and outcomes after TKA. Using NIS
data, Gwam and coworkers found signicant racial differences in age of presentation, health, and income status of TKA patients (Gwam etal. 2019a).
> The authors found that black patients underwent
TKA at a younger age, lower median household
income, and decreased age-adjusted Charlson comorbidity index.
Racial and ethnicity effects on primary TKA outcomes
have also been studied. Zhang used 8years of SID data
from 8 racially diverse states, studying Arizona, Colorado, Iowa, North Carolina, New Jersey, Rhode Island,
Wisconsin, and Florida from 2001 to 2008 (Zhang etal.
2016).
> Racial disparities were found with respect to mortal-
ity and complications after adjusting for patientrelated and healthcare system characteristics.
The risk of perioperative mortality was signicantly
higher for black, Native American, and mixed-race
patients than for white patients. In addition, the rates of
in-hospital complications were signicantly higher for
black and mixed-race patients than for white patients
in these specic states. On the other hand, using ACSNSQIP data for 62,075 primary elective TKAs, Cram
found similar 30-day complication rates after TKA for
white and black patients (Cram etal. 2018).
Regarding gender, Cram et al. examined the same
ACS-NSQIP database for 62,075 primary, elective
TKAs and found that while women had markedly higher
complication rates than men, the differences were driven
almost entirely by higher rates of blood transfusion in
women.
> Gender should further be explored in future publica-
tions.
39.4.1.2 Region
State-based data have also been used to assess utilization for individual states. For example, the Massachusetts
SID captures 100% of inpatient data. This data set from
2002 to 2011 showed an increase in TKA incidence by
80% from 10.8 procedures per 10,000 population in 2002
to 19.4in 2011 (Kurtz etal. 2016). Gwam etal. (2019a)
identied the Midwest region with the fastest growth per
capita, as compared to the Northeast, South, and West
regions (Gwam etal. 2019a). Regarding regions with largest current patient populations, the Medicare database
within the PearlDiver data set indicated that the highest
volumes of TKA procedures are in the South but the average reimbursement rates are highest in the Northeast and
lowest in the Midwest (Nwachukwu etal. 2015).
39.4.1.3 Age
Nwachukwu etal. examined 2,040,667 TKAs in the 2005
to 2011 Medicare database of PearlDiver and showed that
TKAs were performed most frequently on patient ages
65–69, which was also the age group with the lowest reimbursement cost per procedure ($10,956) (Nwachukwu
et al. 2015). TKAs were performed least frequently in
patients 84+ years old and surgeries in this group had the
highest amount reimbursed per procedure ($11,838).
In-hospital complication rates in octogenarians and
nonagenarians undergoing revision TKA have been
examined using NIS data (Smith etal. 2019). Based on
30,471 revision TKAs between 2010 and 2014, nonagenarians were found to have signicantly longer lengths of
stay (5.88 vs. 4.88days) and higher total charges ($98,828
vs. $86,203) than octogenarians. Nonagenarians also had
a signicantly higher inpatient mortality rate (2.73% vs.
0.81%) than octogenarians. They tended to develop pneumonia or pneumonitis (1.28% vs. 0.44%), urinary tract
infection (14.06% vs. 7.20%), acute kidney injury (15.28%
vs. 8.73%), and cardiogenic shock (0.26% vs. 0.02%) at a
signicantly higher rate than octogenarians. Orthopedic
surgeons can expect increased rates of some complications in nonagenarians undergoing revision TKA.
> As such, orthopedic surgeons need to be alert to inpa-
tient postoperative management of nonagenarians to
help mitigate some of the increased risk of select
postoperative complications, and to thereby help to
reduce length of stay and total charges.
39.4.2 Comorbidities
39.4.2.1 Smoking andMalnutrition
The ACS-NSQIP database was used to identify patients
who underwent revision TKA between 2006 and 2014
(Bedard etal. 2018). Of the 8776 revision TKA patients,
opioid use disorder
Day of surgery 90-day costs of care
$10,000.00
$11,000.00
$12,000.00
$13,000.00
$14,000.00
$15,000.00
$16,000.00
$17,000.00
$18,000.00
$19,000.00
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11.6% were current smokers. Multivariate analysis
identied current smokers as being at a signicantly
increased risk of any wound complication and deep
infection after revision TKA.There was also a strong,
albeit insignicant (p=0.051) trend toward re-operation
in smokers compared to non-smokers.
Malnutrition as measured by low serum albumin
has been shown to increase the rate of perioperative
complications in primary total joint arthroplasties
including TKAs. An ACS-NSQIP study by Kamath
etal. further showed that patients with low serum albumin (<3.5 mg/dL) were more likely to develop deep
surgical site infection, organ space surgical site infection, pneumonia, urinary tract infection, and sepsis
(Kamath etal. 2017).
Modiable risk factors, such as smoking and malnutrition, can have an impact on postoperative complications.
> Therefore, greater attention needs to be placed on
better understanding of whether smoking cessation
programs could help reduce these postoperative com-
plication risks, and whether hypoalbuminemia may be
used to help identify higher risk patients.
39.4.2.2 Opioid Use Disorder andAssociated
Adverse Events
Opioid use disorder (OUD) is associated with adverse
health events and increased odds of developing venous
thromboembolism (VTE) (Vakharia et al. 2019). To
determine whether opioids affect the outcome of primary TKA, Vakharia etal. evaluated patients with OUD
after TKA for the presence of VTEs, re- admissions, and
costs of care (Vakharia etal. 2019). The study compared
10,929 patients with OUD vs. 43,551 patients without
OUD who underwent TKA between 2005 and 2014
using the Medicare Standard Analytical Files from the
PearlDiver database.
> Compared to patients without OUD, patients with
OUD had higher incidence of VTE in the 90days following primary TKA surgery (2.48% vs. 1.10%). In
addition, re-admission rates and costs of care were
both higher in patients with OUD (.
Jones et al. sought to characterize the impact of the
opioid-based analgesia after TKA. Specically, they
focused on the incidence and clinical/economic impact
of opioid-related adverse drug events (ORADEs) (Jones
Fig.39.2).
p < 0.0001
$18,380.89
$15,565.57
Opioid use disorder
Non-
p < 0.0001
$13,360.73
$11,911.94
. Fig. 39.2 Day of surgery and total global 90-day episode of care costs among opioid use disorder and non-opioid use disorder patients
following primary TKA. (Adapted from Vakharia etal. 2019, with permission from Elsevier) (Vakharia etal. 2019)
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etal. 2019). The study population consisted of 316,858
patients who underwent TKA between 2016 and 2017
from the Medicare Limited Data Set, which represents
approximately 35% of all inpatient hospital discharges
in the United States. Potential ORADE occurrence was
determined using a series of ICD-10 codes that included
codes for events including drug-induced constipation,
altered mental status, different types of acute respiratory
failure, and others. The incidence of potential ORADE
in these patients was determined to be 8%. Patients who
experienced at least one ORADE had longer hospital
stays compared to patients without an ORADE (3.42 vs.
2.38days). In addition, ORADEs resulted in lower daily
hospital revenue per day in discharges ($4680 vs. $6014).
Lastly, ORADEs were associated with increased risk of
clinical conditions such as pneumonia, shock, septicemia, gastrointestinal hemorrhage, and acute myocardial
infarction.
Gonzales et al. also evaluated the risk, incidence,
and expense associated with potential opioid-related
adverse events after primary and revision TKA (Gonzales et al. 2018). Using the Medicare 5% Limited
Data Set, 41,702 TKA patients and 3817 revision TKA
patients were analyzed. At 90days after surgery, respiratory complications, postoperative nausea and vomiting,
and urinary retention were the most common ORADEs
after primary and revision TKA.Suffering an ORADE
increased medical costs by 39% for primary TKA
patients and 26% for revision TKA patients.
39.4.2.3 Disease
Quinlan etal. evaluated whether multiple sclerosis (MS)
was a potential risk factor for complications following TKA (Quinlan etal. 2019). The study included 6437
patients with a history of MS and 64,370 patients from a
matched control cohort, all of whom underwent primary
TKA between 2005 and 2014, using the PearlDiver patient
records from a Medicare database. Compared to patients
without MS, patients with a history of MS had signicantly higher rates of hospital re-admissions and emergency room visits within 30days postoperatively, as well
as periprosthetic joint infection within 2years postoperatively and longer stays with higher costs accrued overall.
However, patients with MS were not at increased risk of
postoperative stiffness, revision surgery, or mortality.
> This research indicates that MS patients who require
TKA should be provided appropriate counseling
regarding the increased risks of complications.
length of stay, re-admission rates, complications, and
costs of care. The study evaluated 8196 patients with
schizophrenia and 40,980 matched patients without
schizophrenia within the Medicare claims database.
Schizophrenia resulted in signicantly longer hospital stays (3.73. vs. 3.22days) and higher re-admission
rates (18.3% vs. 12.1%). In addition, medical and
implant-
related complications were both higher in
patients with schizophrenia compared to controls.
Generally, schizophrenia patients had higher costs of
total care.
> Ultimately, schizophrenia may be a risk factor follow-
ing TKA and patients should be informed of the elevated levels of risks if suffering from schizophrenia.
39.4.2.4 Immunosuppression
Curtis evaluated perioperative and 30-day outcomes
in 3466 chronically immunosuppressed patients who
undergo primary TKA for osteoarthritis from 2008- 2014
ACS-NSQIP data, with 108,158 patients in a control
group (Curtis etal. 2018). The chronically immunosuppressed group patients were more likely to be younger and
female with a lower BMI.Immunosuppressed patients
were dened as those with the need for oral/IV corticosteroids or immunosuppressant drugs, such as Prednisone,
Decadron, or Cyclosporine. Immunosuppressed patients
were at higher risks of developing organ/surgical site
infection, wound dehiscence, deep venous thrombosis
(DVT), pneumonia, urinary tract infection, systemic sepsis, and re-admission.
> Immunosuppression is a risk factor for surgery and
surgeons should be aware of the complications
involved with operating on an immunosuppressed
patient.
39.4.2.5 Obesity
Discharge records from the NIS data set showed that
the proportion of morbid obesity increased almost 3
times in TKA patients from 2006 to 2014 (Wang etal.
2019). The effects of obesity on VTE has been examined
using ACS-NSQIP data from 2008 to 2016 by Sloan
etal. (2019). From 218,997 primary TKAs, they found
the risk of pulmonary embolism (PE) being elevated,
but not DVT, for overweight and obese primary TKA
patients. BMI as a continuous variable, meaning the
value exists as part of a range, was associated with an
2
odds ratio of around 1.03 for each increase in kg/m
.
Vakharia etal. sought to determine the inuence of
schizophrenia on primary TKA outcomes (Vakharia
etal. 2019). Specically, they investigated the hospital
> A suggested optimal cut point for BMI among
patients undergoing primary TKA to maximize sensitivity and specicity of risk for PE was 33.0kg/m
2
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Combined VTE (DVT or PE resulting in treatment)
within 30days of surgery was not associated with BMI
as a continuous variable for patients undergoing primary TKA.
The NIS data set has been used to evaluate obesity
trends in revision TKAs as well. Based on 451,982 revision
TKA patients using 2002-2012 NIS data set, the obesity
rate among revision TKA patients more than doubled
during this 10-year period, increasing signicantly from
9.74% in 2002 to 24.57% in 2012 (Odum et al. 2016).
After adjusting for all factors, revision patients treated
in 2011 or 2012 were over 4 times as likely to be obese,
compared to revision patients treated in 2002. Female
revision patients and revision patients between the ages
of 45 and 64years were independently associated with
higher obesity rates. This means that no matter the year
studied, female revision patients and revision patients
between the ages of 45 and 64 were more likely to be
obese than other revision TKA patients. The effects of
obesity on the potential for experiencing a VTE have
also been examined using ACS-NSQIP data from 2008
to 2016 by Sloan etal. (2019). They found no association between obesity and increased risk of PE, DVT, or
combined VTE for 15,286 revision TKA patients.
In 2014, approximately 10% of morbidly obese TKA
patients were also undergoing bariatric surgery as shown
in the 2006-2014 discharge records from the NIS data
set (Wang et al. 2019). This data set also showed that
TKA patients with prior bariatric surgery had a lower
risk of pulmonary embolism, respiratory complications,
death, and shorter length of stay, but also had a higher
risk of blood transfusion and anemia.
With the evident trend toward patients with higher
BMIs, particularly in the revision TKA category, surgeons will benet from this research into the optimal
BMI cutoff point for primary TKA surgery and the
increased risk of PE for obese primary TKA patients,
as well as the potential benets of bariatric surgery and
general knowledge of the associated risk factors.
39.4.3 Surgical Technique
39.4.3.1 Computer Navigation
Computer navigation and robotic assistance surgeries
have been introduced in total joint replacement to provide
improved accuracy in component positioning. From the
2005–2014 NIS data set, 6,060,901 TKA surgeries were
examined, including 273,922 (4.5%) who used computer
navigation and 24,084 (0.4%) who used robotic assistance
(Antonios etal. 2019). The proportion of robotic-assisted
or computer navigation in TKAs steadily increased over
the study period from 1.2% in 2005 to 7.0% in 2014.
However, the use of these technologies was associated
with increased hospital charges, averaging $53,740 per
procedure compared to $47,639 for conventional TKA,
but the elevated charges appeared to be driven by computer navigation rather than robotic assistance. Most technology-assisted TKAs were performed in urban hospitals,
on Caucasian patients who were Medicare beneciaries.
Though the prevalence of advanced techniques in TKA
surgeries is limited thus far, it is increasing steadily. More
research into the revision rates with advanced surgeries
versus traditional techniques would benet this eld.
39.4.3.2 Bilateral TKAs, Staged TKAs,
Combined THA/TKA, andInpatient
vs. Outpatient Surgery
Rarer procedures such as combined THA and TKA
have also been evaluated using national healthcare databases. Using the 2005–2014 NIS data set, Almaguer 2019
compared in-hospital outcomes of combined total joint
arthroplasty (TJA), as dened as total hip arthroplasty
(THA) and total knee arthroplasty (TKA) performed
during the same admission, vs. bilateral THA, bilateral
TKA, single THA, and single TKA (Almaguer et al.
2019). During that period, a total of 1690 (0.0002%)
patients underwent combined TJA during the same hospital stay, while 32,763 (0.3%) underwent bilateral THA
and 388,812 (3.6%) underwent bilateral TKA during the
same hospital admission. Single THA was performed
in 3,524,055 (32.7%) patients, while 6,835,843 (63.4%)
underwent single TKA.
> Combined TJA was associated with increased risk of
deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty, extended length of stay (LOS), and increased
in-hospital costs compared with bilateral THA, bilateral TKA, single THA, and single TKA.
A study of the Humana subset of the PearlDiver database showed that as compared with simultaneous bilateral TKA, staged TKAs occurring within 12months of
each other had higher odds of mechanical complications and infection but lower odds of transfusion and
re-admission within 90days for any reason (Richardson
etal. 2019). Those patients with staged surgeries much
less than 3months apart had signicantly higher odds of
undergoing manipulation under anesthesia. The study
included 7747 patients, with 1637 of those undergoing
simultaneous bilateral TKA.
With regard to the concern surrounding the healthcare expenditures in the United States, studies into the
national trends and complication rates for inpatient
vs. outpatient TKAs have been performed. Outpatient
surgeries were more likely to necessitate revision for
non- infectious reasons, removal, irrigation and debride-
456
35,000
Number of pateints (inpatient)
Number of pateints (outpatient)
Age distribution
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30,000
25,000
20,000
15,000
10,000
5000
0
than 40
. Fig. 39.3 Age distributions of patients undergoing TKA as
either inpatient (blue) or outpatient (red) with Humana insurance.
The age distributions were statistically comparable between the 2
Less
Inpatient
Outpatient
40–44 45–49 50–54 55–59 60–64
1000
800
600
400
200
0
65–69 70–74 75–79 80–84 85–89 90 and
above
groups, with median age in the 70- to 74-year age group. (From Arshi
etal. 2017, by courtesy of Wolters Kluwer Health, Inc.) (Arshi etal.
2017)
ment, stiffness requiring manipulation under anesthesia, postoperative deep vein thrombosis, and acute renal
failure than inpatient surgeries (Arshi etal. 2017). The
Humana subset of the PearlDiver database from 2007 to
2015 was used and tracked patients for up to 1 year after
surgery. A total of 4391 outpatient surgery recipients
39
and 128,951 inpatient surgery recipients were included
in the study (. Fig.39.3).
Combined TJA is associated with additional risks
compared to any other operations involving combinations of knee or hip arthroplasties. In addition, the
complication rates for outpatient TKAs are higher than
inpatient procedures.
> Surgeons will benet from this information when con-
sidering the appropriate operative approach, and
patients considering TJA or outpatient procedures
should be warned of the associated risks.
39.4.3.3 Cemented vs. Cementless
Selective use of cementless TKA has been demonstrated
in several studies. Gwam 2019 studied the epidemiology of cemented and cementless TKA based on ICD-10
codes in the NIS data set from October 1 to December
31, 2015 (Gwam et al. 2019b). From 167,930 TKAs,
only 2.9% (n = 4870) were identied as cementless
TKA.Cemented TKA patients were found to be older,
mostly women, residing outside of the Northeast, and
being insured by Medicare.
> Cementless TKA procedures had signicantly higher
total inpatient mean costs ($16,010) compared to
cemented TKA procedures ($15,394).
But they also had signicantly higher odds of being discharged to home, with other options including inpatient
rehabilitation, discharge to a skilled nursing facility, or
under home health care.
No association was identied between type of xation and acute renal failure, urinary tract infection,
pulmonary embolism, supercial surgical site infection,
postoperative pneumonia, or deep vein thrombosis,
which encompasses all of the complications in scope for
this study. The eld would benet from more data setbased research into the revision rates of cemented vs.
cementless xation.
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39.4.4 Infection
Use of antibiotic-loaded bone cement in TKAs is common practice, despite the controversy surrounding it.
The concern comes from the multiple adverse events
associated with its use as compared to the potential
reduction in infection risk.
> The data included from 1,184,270 surgeries in the
Premier Healthcare claims database from 2006 to
2016 showed that antibiotic-loaded bone cement was
used in 17.3% of TKA surgeries in 2006 and grew to
30.2% in 2010, when use plateaued (Chan etal. 2019).
Utilization was lower in rural hospitals (21.4% of surgeries), but higher in hospitals with over 500 beds
(29.4%). Use of antibiotic-loaded bone cement was
associated with a reduced incidence of early postoperative infections, but also with increased odds for acute
kidney injury.
Slifka et al. investigated the effects of prosthetic
joint infection (PJI) after TKA on mortality rates using
claims data from the 2004 to 2012 Medicare 5% sample
Standard Analytic Files (Slifka etal. 2018). A total of
80,429 TKAs were included in the study, and 1% were
diagnosed with PJI. The crude mortality rate was 3.7
times greater in patients with PJI than without PJI following TKA. After accounting for comorbid conditions and additional dependent factors, the risk of death
with PJI vs. non-PJI was still 2.6 times higher following
TKA. The study results supported the importance of
better understanding risk factors for PJI following TKA.
Cancienne etal. investigated the clinical outcomes of
patients who experienced PJI following primary TKA,
had their prostheses removed, and received an antibiotic spacer (Cancienne et al. 2018). A total of 18,533
patients were included in the study using Medicare data
from PearlDiver. Complications within 1year of antibiotic spacer placement included death in a hospital
setting (3.7%), joint fusion (4.5%), amputation (3.1%),
and repeat debridement procedures (14.5%). 12.5% of
the patients retained their spacers without re-implantation, and 61.6% underwent spacer removal and reimplantation within 1year. The study also found that
multiple risk factors were associated with complications
following antibiotic spacer placement, including, but
not limited to, obesity, peripheral vascular disease, and
tobacco/alcohol use/abuse.
> Ultimately, the study provided sobering data on the
fate of patients who experience PJI and need antibi-
otic spacers, and further investigation is necessary to
eradicate infection while minimizing morbidity and
mortality of these patients.
39.4.5 Postoperative Care
Database information can also lend insight into the
tendencies for postoperative care in different regions of
the United States, different insurance types, and different xation methods. Gwam etal. found that implantation with a cementless TKA was associated with higher
probability of being discharged home vs. implantation
with a cemented TKA (Gwam etal. 2019b). Soley-Bori
etal. found that patients in the Northeast were 2.5 times
more likely to be discharged to an extended care facility
as compared with patients in the South who tended to
be discharged home (Soley-Bori etal. 2017). Similarly,
those enrolled in private insurance HMO/PPOs were
more likely to use extended care facilities vs. those in
non-capitated plans such as fee-for-service or exclusive provider organizations, though this did not hold
true for the Northeast. The Truven Health Analytics
MarketScan inpatient database from 2009 and 2010
was used for this study, and 110,643 patients met the
inclusion criteria. Only 10% of these patients were discharged to an extended care facility, and large variation
was observed across the states. The average patient age
was 45years, 51% were women, 30% had between two
and four comorbidities, and 15% had diagnosed obesity.
Those discharged to an extended care facility tended
to be older, female, more obese, diagnosed with more
comorbidities, and wealthier.
Furthermore, a study using the Truven Health
MarketScan databases from 2009 to 2013 showed that
primary and revision TKA patients were discharged to
home under self-care at approximately the same rate
(40.2% for primary, 40.6% for revision) (Nichols and
Vose 2016). Home health organizations cared for 36.6%
and 37.3% of primary and revision TKA patients,
respectively, and 14.0% of primary TKA and 13.4% of
revision TKA patients were discharged to skilled nursing facilities. Complications, transfusions, and a length
of stay greater than 3days were associated with greater
odds of discharge to home with home health services
support or to a skilled nursing facility as opposed to
home under self-care. Discharge to a skilled nursing
facility or home with home health services was then
associated with a greater risk for re-admission. Readmission occurred in 14.8% and 23.1% of primary
and revision TKA patients, respectively, and 76.8% of
primary patients stayed over 3days for their index hospitalization as compared to 75.7% of revision patients.
A total of 323,803 primary TKAs and 25,354 revision
TKAs met the inclusion criteria and were followed for
90days.
Home health care and physical therapy (PT) utilization following TKA procedures is increasing. Falvey etal.
sought to determine a relationship between home health
458
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C. Bergerson et al.
39
care PT utilization and functional recovery, as well as
investigate any factors that may inuence PT utilization
after TKA (Falvey etal. 2018). A total of 5967 Medicare
patients who received home health care services in 2012
were analyzed. After adjusting for factors such as age, sex,
and baseline physical function, patients who received 6 PT
visits or more reported signicantly improved functional
scores in activities of daily living compared to patients
who received 5 or less PT visits. Living in a rural location,
dyspnea, and depressive symptoms were all associated
with lower PT utilization. These results suggest that more
than 6 home health care PT visits promote functional
recovery, and that certain patient populations should be
monitored to ensure appropriate PT utilization.
> These data revealed that region within the nation and
insurance type are more inuential to the postoperative care plan of a patient compared to whether that
patient is undergoing a primary or revision surgery.
> These studies also show the importance of routine PT
postoperatively and provide information that can be
used to screen for patients at risk for under-
39.4.6 Preventing Venous Thromboembolic
utilization.
Events
The ideal agents for prevention of venous thromboembolic events (VTEs) after TKA is a topic of debate. Bala
etal. compared VTE incidence after TKA with the use
of four agents: aspirin, enoxaparin, warfarin, or factor Xa inhibitors (Bala etal. 2017), and Runner etal.
have compared the outcomes of less aggressive (i.e.,
aspirin) vs. more aggressive (e.g., enoxaparin and warfarin among others) prophylactic treatment strategies
(Runner etal. 2019). Specically, the occurrences of deep
venous thrombosis (DVT) and pulmonary embolism
(PE) were investigated by Bala by looking at a total of
18,288 patients from Medicare and Humana databases
between 2007 and 2016, and a total of 22,072 cases of
primary joint arthroplasty (combined TKA and THA)
between 2014 and 2016 using the ABOS case list database were assessed by Runner. The use of less aggressive treatments was associated with a lower rate of DVT
and PE events at 90days post-surgery (Bala etal. 2017).
Furthermore, less aggressive treatments had a lower
likelihood of mild (0.2% vs. 0.9%) and moderate (0.4%
vs. 1.2%) thrombotic events, as well as mild, moderate,
and severe bleeding events. Less aggressive strategies
also were less likely to lead to infection or death within
90days post-surgery (Runner etal. 2019). Only 3% or
less of patients using aspirin or Factor Xa inhibitors
had DVT events within 90days following TKA, while
3.5% of patients using enoxaparin and 4.8% of patients
using warfarin had DVT events within 90days. These
differences were statistically signicant. Similarly, PE
events occurred in between 0.9% and 1.2% of patients
using aspirin, Factor Xa inhibitors, or enoxaparin with
90 days, while PE occurred in 1.6% of patients using
warfarin, which was again a statistically signicant difference. Patients with aspirin demonstrated the lowest
risk of bleeding, though the differences in occurrence
between the therapies were not statistically signicant.
The utilization of aspirin and factor Xa inhibitors
after TKA grew 30% and 43% respectively from 2007
to 2015, while utilization of enoxaparin and warfarin
remained relatively constant over the timespan (Bala
etal. 2017). However, less aggressive strategies were used
less frequently compared to more aggressive strategies in
the study population (45.4% vs. 54.6%).
> Patients receiving less aggressive prophylactic treat-
ment strategies were signicantly more likely to have
fewer or no complications with the TKA or THA
compared to more aggressive strategies (95.5% vs.
93.0%).
Further research into this topic is being undertaken in
the Comparative Effectiveness of Pulmonary Embolism
Prevention after Hip and Knee Replacement (PEPPER)
trial (Bala etal. 2017).
39.4.7 Future Trends inTKA
The use of large national-based databases provides an
excellent resource for estimating the future use of TKA
(Inacio etal. 2017). Projections based on logistic regression modeling of NIS data from 1993 to 2012 estimated
TKA incidence to increase 69% by 2050 compared to
2012, from 429 procedures per 100,000 persons in 2012
to 725in 2050, which corresponds with a 143% projected
increase in total number of TKA procedures performed
Fig.39.4). Taking a less conservative approach using
(.
Poisson modeling, the TKA incidence has been projected
Incidence (per 100,000) of TKA in the US
4000
Year
2050
Poisson model, 2000–2030
2000
2005 2010 2015 2020 2025 2030
THA
Annual pocedures (n)
A
US National Databases– Total Knee Arthroplasty: Lessons Learned
https://t.me/medicina_free
459
39
Logistic
Poisson
3000
2000
1000
0
1990
2000 2010 2020 2030
. Fig. 39.4 Historical (1993–2012) and projected (2015–2050) inci-
dence rates per 100,000 procedures of primary TKA procedures in
citizens 40 years old and older from Logistic and Poisson models.
(From Inacio 2017, with permission from Elsevier) (Inacio et al.
2017)
2040
to increase 565% over the same time frame, to 2854 procedures/100,000 persons by 2050, representing an 855% projected increase in the total number of TKA procedures
compared to 2012. Sloan etal. also offered an estimation
using Poisson modeling, and predicted the increase by
2030 to be 147% (to 1.68 million), on the basis of the 2000
to 2014 NIS data (. Fig.39.5) (Sloan etal. 2018).
Others have also used different modeling methods,
such as polynomial regression and linear projection, to
account for the non-linearity and interactions between
variables (Singh et al. 2019). Compared to 2014, the
total annual primary TKA surgeries in the United States
are projected to increase by 56% in 2020, 110% in 2025,
182% in 2030, and 401% in 2040. Sloan etal. sampled
the NIS data set and used linear projection to predict
that by 2030, TKA volume would increase by 84.9% (to
1.26 million) (. Fig.39.6) (Sloan etal. 2018).
> All models have indicated an increase in the annual
volume of TKA procedures in the coming years.
Further research is necessary to understand and pre-
dict TKA utilization, and database information pro-
vides the appropriate sample sizes and distributions
from which to make these estimations.
. Fig. 39.5 Data predicting the
utilization from 2000 to 2030
based on the NIS data set with a
Poisson Model (Sloan etal.
2018)
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
8,00,000
6,00,000
4,00,000
2,00,000
Primary
Primary TK
0
Linear model, 2000–2030
THA
2000 2005 2010 2015 2020 2025 2030
Annual procedures (n)
C. Bergerson et al.
https://t.me/medicina_free
39
460
. Fig. 39.6 Data predicting the
utilization from 2000 to 2030
based on the NIS data set with a
Linear Model (Sloan etal. 2018)
Conclusion
z
1,400,000
1,200,000
1,000,000
8,00,000
6,00,000
4,00,000
2,00,000
0
Administrative claims data and large-scale databases
have taken on an inuential role within the orthopedic
surgery literature. The large sample sizes over many years
and excellent capture of billable procedures or complications such as mortality remain the major advantages
of their use.
Take-Home Messages
5 Administrative claims data sets and large clinical
registries offer powerful insight into how practices
vary depending on region, insurance type and race,
even after accounting for differences in the healthcare system. This type of objective insight is necessary to identify and address problems facing
American surgeons and patients.
5 To date, the study of cementless TKAs using
administrative claims data sets and large clinical
registries has been limited. However, current studies indicate that cementless TKAs were associated
with increased costs with similar complication
rates compared to cemented TKAs.
5 Various diseases and comorbidities can have surpris-
ing correlations to complications after TKA, such as
patients with opioid use disorder being more prone
to experiencing VTE than a control population.
5 More work in the areas of gender dynamics, inu-
ence of robotic surgeries on TKA revision rates,
and the inuence of cementless vs. cemented xation on revision rates would benet the eld.
5 And importantly, the lack of standardization
between these databases often makes data difcult
to compare. Care and attention are necessary when
drawing conclusions from these immensely useful
data sets.
Primary
Primary TKA
5 Cementless TKA procedures had signicantly
higher total inpatient mean costs ($16,010) compared to cemented TKA procedures ($15,394).
5 From 1,184,270 surgeries in the Premier Health-
care claims from 2006 to 2016, antibiotic-loaded
bone cement was used in 17.3% of TKA surgeries
in 2006 and grew to 30.2% in 2010, but plateaued
thereafter.
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