Aims The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Results Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Conclusion Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485–494.

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Introduction: Revision total hip arthroplasty (rTHA) is becoming a more common procedure due to the increasing volume of primary total hip arthroplasty. Diabetes mellitus (DM) is currently projected to affect 4.4% of the global population by 2030. Diabetes has been associated with poor outcomes for a variety of surgical interventions. However, the impact of insulin dependence has yet to be fully understood. The aim of this study was to determine the impact of insulin dependence on acute postoperative complications following rTHA. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. All patients who underwent rTHA between 2006 and 2016 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM) or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after rTHA. Results: A total of 7685 patients were evaluated (No DM = 6651, NIDDM = 700, IDDM = 334). Univariate analysis revealed that all patients with DM had significantly higher incidences of postoperative complications (NIDDM: p < 0.001; IDDM: p < 0.001) and extended hospital length of stay (NIDDM: p = 0.015; IDDM: p < 0.0001). NIDDM was associated with increased rates of superficial surgical site infection (SSI) ( p = 0.001), deep SSI ( p = 0.038), and stroke ( p = 0.013), while IDDM was associated with increased rates of pneumonia ( p < 0.001), renal failure ( p < 0.001), and postoperative transfusion ( p < 0.001). On multivariate analysis, insulin-dependence was determined to be an independent risk factor for extended hospital length of stay (OR 1.905; 95% CI, 1.410–2.577; p < 0.001), pneumonia (OR 4.016; 95% CI, 1.799–8.929; p = 0.001), renal failure (OR 7.143; 95% CI, 2.203–23.256; p = 0.001) and postoperative transfusion (OR 1.366; 95% CI, 1.076–1.733; p = 0.01). Conclusions: Insulin dependence is an independent risk factor for numerous short-term postoperative complications following rTHA. When assessing risk and planning perioperative management, surgeons should consider insulin-dependent diabetics as a sub-cohort within the diabetic population.

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Introduction: Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption.Methods: Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses.Results: A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864).Discussion: The DAA was associated with slightly lower patientreported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.

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