Risk stratification in primary total joint arthroplasty: the current state of knowledge

Abstract

Background As we transition to value-based care delivery models, risk stratification in total joint arthroplasty is more important than ever. The purpose of this study was to identify patients who would likely require higher level of care and may not be suitable for inclusion in bundled payment models. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent primary total joint arthroplasty between 2011 and 2012. Five types of adverse events were assessed: medical complications, surgical complications, readmission, reoperation, and mortality. Univariate and multivariate logistic regression analyses were performed using a large number of demographic and morbidity variables. Results A total of 14,185 patients were identified. The 30-day medical complication, surgical complication, readmission, reoperation, and mortality rates were 2.0%, 3.2%, 4.0%, 1.5%, and 0.2%, respectively. Among the different variables assessed, only the American Society of Anesthesiologists (ASA) physical classification system was a significant risk factor for most outcomes assessed. Peripheral vascular disease was the most significant risk factor for medical complications and reoperation (odds ratio, 2.73 and 3.23, respectively). Bleeding disorders were the most significant risk factor for readmission and mortality (odds ratio, 2.03 and 5.86, respectively). Conclusions ASA score is a more reliable risk stratification tool than Charlson Comorbidity Index, but it is not sufficient by itself. Patients with higher ASA scores combined with peripheral vascular disease and/or bleeding disorders are at especially high risk of developing postsurgical adverse events and may not be suitable for inclusion in bundled payment models. These data can be used to develop better risk stratification models that are critically needed.

Albumin and the fibrinogen-to-albumin ratio: Biomarkers for the acute phase response following total knee arthroplasty

“…Furthermore, there were no significant differences in age-adjusted CCI between patients included and those excluded for rheumatoid arthritis or revision surgery due to infection; although the risk for complications was higher amongst the excluded patients [ 56 – 58 ]. Together, this data aligns with recent reports suggesting that CCI may not be a sensitive predictor to patient postoperative outcomes following primary total joint arthroplasty [ 53 ]. Given the preoperative variance in CRP and FAR between included and excluded patient cohorts, future prospective studies are warranted to examine the positive predictive capacity of preoperative CRP and FAR to predict adverse postoperative outcomes.…”

Intra-articular saline injection is as effective as corticosteroids, platelet-rich plasma and hyaluronic acid for hip osteoarthritis pain: a systematic review and network meta-analysis of randomised controlled trials

“…Although largely successful, 3 4 TJA represents major surgery that is associated with small but important risk of complications and unsatisfactory results. 5 Thus, it is important that all non-operative options are explored and exhausted for a patient with hip or knee OA, particularly in younger patients where implant longevity is a real concern. 6 Non-operative treatment for hip and knee OA consists of a stepwise approach, which in reality is generally deployed in a parallel and multimodal manner.…”

Total Joint Arthroplasty During the COVID-19 Pandemic: A Scoping Review with Implications for Future Practice

“…Notably, the results of the present study demonstrate that the COVID-19 pandemic highlights previous trends in arthroplasty, including patient risk stratification and the importance of outpatient surgery. In the arthroplasty literature, there has been an emphasis on the risk stratification of patients, as it may limit potential complications and allow for the appropriate allocation of perioperative resources [ 53 ]. Further, prior to the pandemic, there has been a recent trend toward outpatient arthroplasty due to the favorable outcomes and cost savings metrics.…”