Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness. We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination. In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications. In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA.
There has been growing interest in the literature regarding evaluation of functional outcomes in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) while suffering from depression and using selective serotonin reuptake inhibitors (SSRI). Previous literature has shown that these patients have lower post-operative functional scores compared to those without SSRI use and with multiple musculoskeletal co-morbidities. This might be the result of potentially suboptimal motivation and participation in the post-operative rehabilitation programs. One recent study from a single center has suggested a reduction in adverse events in patients undergoing arthroplasty while on SSRI. The purpose of this study is to evaluate the post operative functional scores of patients on SSRI and compare them with the patients not prescribed SSRIs. A retrospective data analysis was performed on patients who had primary TKA and primary THA between 1st June 2014 and 31st May 2017. The patients into two groups. In the first, patients received SSRI for at least one year before the surgery while in group two, patients did not receive SSRI. Outcome measures included Western Ontario and McMaster university osteoarthritis index (WOMAC) and EQ5D5L scores at pre surgery, three months and 12 months post surgery. Chi-square and t test was used to compare categorical variables and continuous variables respectively. Multivariate linear regression was conducted to compare the change of scores between the two groups and was adjusted for age, gender, and comorbidities. These outcome scores were analyzed separately for TKA and THA. In the TKA group, there were 1,452 patients using SSRI and 15,981 not using SSR. In the THA group there were 851 patients using SSRIs and 10,102 patients without SSRIs. The baseline WOMAC for TKA patients was 45.6 for the controls and 41.8 for those patients on SSRIs (p < 0 .001). The baseline EQ5DL was 0.53 and 0.46 in the same groups (p < 0 .001). The baseline WOMAC for THA patients was 39.1 for the controls and 36.2 for patients using SSRIs (p < 0 .001). The baseline EQ5DL scores were 0.43 and 0.37respectively, again indicating patients on SSRI therapy had lower baseline scores (p < 0 .001). There was improvement in WOMAC and EQ5DL scores in all patient groups at 3 months and 12 months. After adjusting for gender, age, comorbidities and baseline score, THA patients not using SSRI showed a greater improvement in their WOMAC and EQ5DL scores than those prescribed SSRIs, WOMAC (p=0.008), EQ5DL (p=0.001). TKA patients showed a similar outcome but only the EQ5DL was statistically significant, WOMAC (p=0.12), EQ5DL (p=0.036). Our results show that patients on SSRI have lower preoperative WOMAC and EQ5DL scores at baseline when compared to patients not undergoing treatment for depression or anxiety with SSRIs. After arthroplasty, patients using SSRIs show significant improvement at 12 months but the improvement is smaller than the group not using SSRIs.
Patients undergoing Joint Arthroplasty received a significant proportion of blood transfusions. In this study, we compared the risk of Deep Infection, and Superficial Infection post operation following Primary Total Hip or Knee replacement in blood-transfused and non-blood-transfused patients. Cohort of patients who underwent primary total Hip or Knee Arthroplasty from April 2012 to March 2015 in Alberta. Patient characteristics, comorbidity, received blood transfusion were collected from electronic medical records, operating room information systems, discharge abstract database, provincial clinical risk grouper data. Deep Infection and Superficial Infection were captured from Provincial Surgical Site Infection Surveillance data. Deep Infection include deep incisional and organ/space infections. Logistic regression analysis were used to compare Deep Infection and Superficial Infection in blood-transfused and non-blood-transfused cohorts, and risk-adjusted for age, gender, procedure type, and co-morbidities. Our study cohort contains 27891 patients, with mean of age at admission was 66.3±10.4, 57.5% female, 49.3% had 1 or more comorbidities. 58.8% underwent Knee Replacement. 11.1% received blood transfusion during hospital stay (Total Hip Replacement (THR) =13.1% and Total Knee Replacement (TKR) =9.7%,). 1.1% had Deep Infection (THR=1.4% and TKR=0.9%) and 0.5% had Superficial Infection (THR=0.5% and TKR=0.5%). Blood-transfused patients got 1.7% Deep Infection and 1.0% Superficial infection. Non-blood-transfused patients got 1.0% Deep Infection and 0.5% Superficial infection. Controlling for age, gender, procedure type, and co-morbidities, the odds of Deep Infection were 1.6 times higher for blood-transfused patients than for non-blood-transfused patients (adjusted odds ratio [OR]=1.6, 95% confidence interval [CI] [1.2–2.2], p=0.004). The odds of Superficial Infection were 2.0 times higher for transfused patients (adjusted OR=2.0, 95% CI [1.3–3.0], p=0.002). Blood transfusion increases Deep Infection and Superficial Infection post-surgery following Primary Total Knee or Hip Replacement. This finding suggests to reduce the unnecessary blood transfusion for patients considering Joint Arthroplasty. Reducing the blood transfusion will save the inpatient cost and decrease the infective complications post-surgery in Hip or Knee Arthroplasty patients.
Many hospitals and orthopaedic surgery teams across Canada have instituted quality improvement (QI) programs for hip and knee arthroplasty. One of the common goals is to reduce hospital length of stay (LOS) in order to improve operational efficiency, patient flow and, by achieving this, provide improved access for patients to arthroplasty surgery. A common concern among surgeons and care providers is that hospital readmission rates will increase if LOS is significantly reduced. This study assesses the relationship between LOS and readmission rates in Alberta over a six year period during a focused QI initiative targeting LOS. Data from all patients undergoing primary elective total hip or knee arthroplasty in Alberta between 2010 and 2015 was captured through a provincial QI program. Patient characteristics captured included age, gender, joint replaced, and pre-surgical co-morbidities. Patient LOS and all-cause hospital readmissions within thirty days from the initial discharge were captured through provincial data repositories, including the Discharge Abstract Database (DAD), operating room information systems, electronic medical records, and comorbidity risk grouper (CRG) data. Three longitudinal analyses were performed: 1) the crude and risk adjusted length of stay and 30-day readmission rates were calculated, 2) the population was grouped into two 3-year subsets and compared using t-test (acute LOS) and chi-square (30-day readmission), and 3) a multivariable regression analyses was performed to determine the rate of change and statistical significance in acute LOS and 30-day readmission between the two time periods. The number of patients undergoing elective lower extremity arthroplasty in the province during the six-year study period (2010–2015) was 48,760 patients. Fifty-nine percent were female and forty-one percent were male. Mean age of the cohort was 66.9 years. Thirty-nine percent of patients had a total hip arthroplasty and 61% had a total knee arthroplasty. Forty-five percent of patients had no pre-surgical risk factors, 27% had one risk factor, and 28% of the patients had 2 or more risk factors. During the quality improvement program risk-adjusted length of stay improved from a mean of 4.82 days (in 2010–2012) to 3.90 days (in 2013–2015) (p<0.01). Controlling for differences in age, sex, joint replaced, and pre-surgery risk factors, the acute LOS declined by 0.32 days between the two time periods (p<0.001). Quality improvement programs that target reduced LOS can avoid increasing 30-day hospital readmission rates. This has significant implications for inpatient resource utilisation for lower extremity arthroplasty surgery and for improving patient flow.
