Preoperative Patient Optimization in Total Joint Arthroplasty—The Paradigm Shift from Preoperative Clearance: A Narrative Review

2021 ◽  
pp. 155633162110309
Author(s):  
Aoife MacMahon ◽  
Sandesh S. Rao ◽  
Yash P. Chaudhry ◽  
Syed A. Hasan ◽  
Jeremy A. Epstein ◽  
...  
Keyword(s):  
Risk Factors ◽  
Total Joint Arthroplasty ◽  
English Language ◽  
The United States ◽  
Joint Arthroplasty ◽  
Opioid Use ◽  
Preoperative Risk ◽  
Joint Infections ◽  
Preoperative Risk Factors ◽  
Preoperative Optimization

Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors—obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use—and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.

Preoperative Risk Factors for Nonhome Discharge of Home-Dwelling Geriatric Patients Following Elective Surgery

2020 ◽  
pp. 073346482094469
Author(s):  
John C. Warwick ◽  
Ethan Y. Brovman ◽  
Sascha S. Beutler ◽  
Richard D. Urman
Keyword(s):  
Risk Factors ◽  
Elective Surgery ◽  
Living Alone ◽  
Preoperative Risk ◽  
Improvement Program ◽  
Surgical Quality ◽  
Preoperative Risk Factors ◽  
Preoperative Optimization ◽  
Mobility Aid ◽  
Geriatric Research

To identify patient risk factors for nonhome discharge (NHD) for home-dwelling older patients undergoing surgery, we performed a retrospective cohort study of patients aged ≥65 years undergoing elective surgery between 2014 and 2016 using the geriatric research file from the National Surgical Quality Improvement Program (NSQIP). Multivariable logistic regression examined the association between preoperative demographics, comorbidities, and functional status and NHD to determine which factors are most strongly predictive of NHD. Risk of NHD was higher among those of age >85 years, age 75 to 85 years, Black race, with body mass index (BMI) >30, dyspnea with exertion or at rest, partially or totally dependent in activities of daily living (ADLs), preoperative steroid use, preoperative wound infection, use of a mobility aid, fall within 3 months, or living alone at home without support. NHDs were statistically more likely among orthopedic, neurosurgery, or cardiac surgery interventions. Understanding individual patient’s risks and setting expectations for likely postoperative course is integral to appropriate preoperative counseling and preoperative optimization.

scholarly journals Prevalence Of Staphylococcus Aureus Colonization In Patients For Total Joint Arthroplasty In South Africa

2020 ◽  
Author(s):  
Jurek Rafal Tomasz Pietrzak ◽  
Zia Maharaj ◽  
Lipalo Mokete
Keyword(s):  
Risk Factors ◽  
South Africa ◽  
Staphylococcus Aureus ◽  
Total Joint Arthroplasty ◽  
Population Group ◽  
Developed Countries ◽  
Joint Arthroplasty ◽  
Joint Infections ◽  
Intranasal Mupirocin ◽  
Mupirocin Ointment

Abstract Background: Periprosthetic joint infections (PJIs) are a major source of morbidity and mortality for patients undergoing Total Joint Arthroplasty (TJA). Staphylococcus aureus (S aureus) colonization is an independent, modifiable risk factor for periprosthetic joint infections. Post-operative infections are reported to be ten times greater in S aureus carriers than in non-carriers in developed countries though recorded data is lacking for the developing world. This study aims to determine the prevalence of S aureus colonization in patients awaiting TJA in South Africa. Methods: We prospectively assessed 119 patients awaiting Total Knee Arthroplasty and Total Hip Arthroplasty between May and October 2016. We screened three separate anatomical sites on each patient for S aureus. Patients with positive cultures were treated with intranasal mupirocin ointment and chlorhexidine body wash. Univariate and comparative statistical analyses to determine risk factors for colonization was conducted using t-tests, Fisher’s exact tests, and chi square analyses. Results: The overall prevalence of Methicillin Sensitive S aureus colonization was 31.9% (n = 38). There were no patients colonized with Methicillin Resistant S aureus. Nasal swabs returned a yield of 81.6% (n=31), with groin swabs and axillary swabs at 39.5% (n=15) and 28.9% (n=11) respectively. Eradication was successful in 94.74% (n=36) after five days treatment. All patients (100%) were decolonized after counseling and repeat eradication treatment. The overall complication rate was 7.6% (n=9). The 30-day readmission rate in the S aureus -colonized group was 7.9% (n=3) as opposed to 7.4% (n=6) in the non-colonized cohort. There were no 60- and 90-day readmissions and no cases were revised at a mean follow-up of 2.26 years. Conclusions: The rate of S aureus colonization in patients undergoing elective TJA in a developing country was 31.9% and is equivalent to reported rates in developed countries. Eradication treatment with combined intranasal mupirocin ointment and chlorhexidine body wash is a successful treatment modality. A larger cohort of patients is recommended to determine risk factors and post-operative septic sequelae in this population group.

Risk factors for new-onset depression or anxiety following total joint arthroplasty: the role of chronic opioid use

2019 ◽  
Vol 44 (11) ◽  
pp. 990-997 ◽  
Author(s):  
Lauren Wilson ◽  
Janis Bekeris ◽  
Megan Fiasconaro ◽  
Jiabin Liu ◽  
Jashvant Poeran ◽  
...  
Keyword(s):  
Risk Factors ◽  
Total Joint Arthroplasty ◽  
Female Gender ◽  
Joint Arthroplasty ◽  
Opioid Use ◽  
Logistic Regression Models ◽  
Chronic Opioid Use ◽  
The Impact ◽  
New Onset

BackgroundSeveral studies have evaluated the impact of preoperative depression on outcomes following total joint arthroplasty (TJA), however few have studied new-onset depression or anxiety after TJA. We aimed to identify the incidence of and risk factors for new-onset depression/anxiety after TJA, specifically focusing on the role of chronic opioid use.MethodsPatients who underwent total hip (THA) or total knee (TKA) arthroplasty from 2012 to 2015 were identified from the Truven MarketScan database. The main outcomes were new-onset depression or anxiety. The main risk factor of interest was chronic opioid use as a proxy for chronic pain; this was classified into three groups: isolated preoperative use, isolated postoperative use, and preoperative use that continued postoperatively. Multivariable logistic regression models were used to obtain ORs and 95% CIs.ResultsOverall, 106 260 TJA procedures were included (34.3% THA/65.7% TKA); new-onset depression and anxiety were observed in 3.6% and 4.8% of patients, respectively. Preoperative chronic opioid use (6.3%; OR 1.88, 95% CI 1.47 to 2.40), isolated postoperative use (10%; OR 2.61, 95% CI 2.08 to 3.28), and continued postoperative use (7.8%; OR 2.08, 95% CI 1.74 to 2.49) were all associated with significantly increased odds of new-onset depression. Additional risk factors included female gender, younger age, comorbid psychological conditions, and hospital readmission within 6 months of surgery. Similar patterns were seen for new-onset anxiety.DiscussionGiven the observed relationship between chronic opioid use and adverse psychological outcomes following TJA, the relationship between these two entities requires further evaluation, specifically to identify if there is a causal relationship.

scholarly journals Prevalence Of Staphylococcus Aureus Colonization In Patients For Total Joint Arthroplasty In South Africa

2020 ◽  
Author(s):  
Jurek Rafal Tomasz Pietrzak ◽  
Zia Maharaj ◽  
Lipalo Mokete
Keyword(s):  
Risk Factors ◽  
South Africa ◽  
Staphylococcus Aureus ◽  
Total Joint Arthroplasty ◽  
Population Group ◽  
Developed Countries ◽  
Joint Arthroplasty ◽  
Joint Infections ◽  
Intranasal Mupirocin ◽  
Mupirocin Ointment

Abstract Background: Periprosthetic joint infections are a major source of morbidity and mortality for patients undergoing Total Joint Arthroplasty. Staphylococcus aureus colonization is an independent, modifiable risk factor for periprosthetic joint infections. Post-operative infections are reported to be ten times greater in Staphylococcus aureus carriers than in non-carriers in developed countries though recorded data is lacking for the developing world. This study aims to determine the prevalence of Staphylococcus aureus colonization in patients awaiting Total Joint Arthroplasty in South Africa. Methods: We prospectively assessed 119 patients awaiting Total Knee Arthroplasty and Total Hip Arthroplasty between May and October 2016. We screened three separate anatomical sites on each patient for Staphylococcus aureus. Patients with positive cultures were treated with intranasal mupirocin ointment and chlorhexidine body wash. Univariate and comparative statistical analyses to determine risk factors for colonization was conducted using t-tests, Fisher’s exact tests, and chi square analyses. Results: The overall prevalence of Methicillin Sensitive Staphylococcus aureus colonization was 31.9% (n = 38). There were no patients colonized with Methicillin Resistant Staphylococcus aureus . Nasal swabs returned a yield of 81.6%(n=31), with groin swabs and axillary swabs at 39.5% (n=15) and 28.9% (n=11) respectively. Eradication was successful in 94.74% (n=36) after five days treatment. All patients (100%) were decolonized after counseling and repeat eradication treatment. The overall complication rate was 7.6% (n=9). The 30-day readmission rate in the Staphylococcus aureus -colonized group was 7.9% (n=3) as opposed to 7.4% (n=6) in the non-colonized cohort. There were no 60- and 90-day readmissions and no cases were revised at a mean follow-up of 2.26 years. Conclusions: The rate of Staphylococcus aureus colonization in patients undergoing elective Total Joint Arthroplasty in a developing country was 31.9% and is equivalent to reported rates in developed countries. Eradication treatment with combined intranasal mupirocin ointment and chlorhexidine body wash is a successful treatment modality. A larger cohort of patients is recommended to determine risk factors and post-operative septic sequelae in this population group.

Sign in / Sign up

Export Citation Format

Share Document